Basic Information
Provider Information | |||||||||
NPI: | 1467602631 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | MARQUETTA | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PHILLIPS | ||||||||
OtherFirstName: | MARQUETTA | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ADULT CASE MANAGER | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 790 ROBERTS DRIVE | ||||||||
Address2: |   | ||||||||
City: | MONTICELLO | ||||||||
State: | AR | ||||||||
PostalCode: | 71655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703672461 | ||||||||
FaxNumber: | 8704606133 | ||||||||
Practice Location | |||||||||
Address1: | 2410 HWY 65 NORTH | ||||||||
Address2: |   | ||||||||
City: | MCGEHEE | ||||||||
State: | AR | ||||||||
PostalCode: | 71654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702223107 | ||||||||
FaxNumber: | 8702226741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2008 | ||||||||
LastUpdateDate: | 09/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.