Provider Demographics
NPI:1114179462
Name:COLLINS, JUDITH GLASS (PHD)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:GLASS
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEADE RD
Mailing Address - Street 2:
Mailing Address - City:NORDLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98358-9618
Mailing Address - Country:US
Mailing Address - Phone:360-379-9448
Mailing Address - Fax:360-379-6882
Practice Address - Street 1:20174 FRONT ST NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7445
Practice Address - Country:US
Practice Address - Phone:360-697-1141
Practice Address - Fax:360-697-2395
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical