Basic Information
| Provider Information | |||||||||
| NPI: | 1134613656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW 06/13-18 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLINS | ||||||||
| OtherFirstName: | KATEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW 06/13/18 | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | N7269 COLBO RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531052525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627498687 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 BAY VIEW RD STE C | ||||||||
| Address2: | |||||||||
| City: | MUKWONAGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531491770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 2623637289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8942-123 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 42170300 | 05 | WI | MEDICAID |