Provider Demographics
NPI:1225894959
Name:COLLINS, KENNETH DANIEL (CPSW, CSHPS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DANIEL
Last Name:COLLINS
Suffix:
Gender:M
Credentials:CPSW, CSHPS
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 3809
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-3809
Mailing Address - Country:US
Mailing Address - Phone:505-330-1884
Mailing Address - Fax:
Practice Address - Street 1:2915 W HISTORIC HIGHWAY 66 RM 1203
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6812
Practice Address - Country:US
Practice Address - Phone:505-870-1483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1336175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist