Basic Information
| Provider Information | |||||||||
| NPI: | 1316275647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | MELODIE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A, N.C.C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACK | ||||||||
| OtherFirstName: | MELODIE | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH ST STE 409 | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6915 TUTT BLVD STE 110B | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809233591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194451292 | ||||||||
| FaxNumber: | 7195916486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2009 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT.0001069 | CO | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | LPC.0006389 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.