Provider Demographics
NPI:1083071039
Name:COLLINS, CHARLOTTE A (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:A
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:417-257-6762
Mailing Address - Fax:172-575-8754
Practice Address - Street 1:1211 PORTER WAGONER BLVD # 23
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1826
Practice Address - Country:US
Practice Address - Phone:417-257-6762
Practice Address - Fax:417-257-5875
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015044205104100000X
MO2018028131104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker