Provider Demographics
NPI:1194361436
Name:COLLINS, CLARISSA
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
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:PO BOX 3183
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3183
Mailing Address - Country:US
Mailing Address - Phone:509-744-1117
Mailing Address - Fax:509-744-3055
Practice Address - Street 1:1404 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-3502
Practice Address - Country:US
Practice Address - Phone:509-744-1117
Practice Address - Fax:509-744-3055
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60999144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health