Basic Information
Provider Information | |||||||||
NPI: | 1831437961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLIAS | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 299 | ||||||||
Address2: |   | ||||||||
City: | HOXIE | ||||||||
State: | AR | ||||||||
PostalCode: | 724330299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708861333 | ||||||||
FaxNumber: | 8708861334 | ||||||||
Practice Location | |||||||||
Address1: | 503 SE LINDSEY ST | ||||||||
Address2: |   | ||||||||
City: | HOXIE | ||||||||
State: | AR | ||||||||
PostalCode: | 724332224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013368300 | ||||||||
FaxNumber: | 4798905364 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2013 | ||||||||
LastUpdateDate: | 08/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 6908M | AR | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 195452795 | 05 | AR |   | MEDICAID |