Provider Demographics
NPI:1235610197
Name:COLLINS, IESHA (MA, LLP)
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-2052
Mailing Address - Country:US
Mailing Address - Phone:231-557-1833
Mailing Address - Fax:
Practice Address - Street 1:17160 130TH AVE
Practice Address - Street 2:
Practice Address - City:NUNICA
Practice Address - State:MI
Practice Address - Zip Code:49448-9450
Practice Address - Country:US
Practice Address - Phone:616-847-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361005570103T00000X
MI6301013775103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist