Provider Demographics
NPI:1215032784
Name:COLLINS, JOHN LESTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LESTER
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3097
Mailing Address - Country:US
Mailing Address - Phone:505-762-4076
Mailing Address - Fax:505-769-4541
Practice Address - Street 1:1600 SUTTER PL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4611
Practice Address - Country:US
Practice Address - Phone:505-769-4531
Practice Address - Fax:505-769-4541
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM362103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN9907Medicaid