Provider Demographics
NPI:1174830046
Name:COLLINS, CYNTHIA REGINA
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:REGINA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3316
Mailing Address - Country:US
Mailing Address - Phone:678-442-8619
Mailing Address - Fax:
Practice Address - Street 1:6 CARLISLE ST # 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121
Practice Address - Country:US
Practice Address - Phone:617-818-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA222647104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical