Provider Demographics
NPI:1225061047
Name:COLLINS, GEORGE COOPER (PHD)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:COOPER
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 1:675 GRAND ST APT 3L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4957
Mailing Address - Country:US
Mailing Address - Phone:718-599-9335
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016653103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVN0851Medicare ID - Type Unspecified
NYQ64503Medicare UPIN