Provider Demographics
NPI:1083767412
Name:COLLIE, RICHARD S (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:S
Last Name:COLLIE
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 OCEAN AVE
Mailing Address - Street 2:#19
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-5383
Mailing Address - Country:US
Mailing Address - Phone:917-232-7259
Mailing Address - Fax:718-709-7471
Practice Address - Street 1:352 7TH AVE
Practice Address - Street 2:STE. 1001
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5012
Practice Address - Country:US
Practice Address - Phone:917-232-7259
Practice Address - Fax:718-709-7471
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080045-11041C0700X
NY076029104100000X
NYR-080045-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400117766Medicare PIN