Basic Information
| Provider Information | |||||||||
| NPI: | 1659915270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | DESTINY | ||||||||
| MiddleName: | J.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1232 EL ENCANTO WAY | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958313123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166703338 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3671 BUSINESS DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958202233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167348396 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2019 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.