Provider Demographics
NPI:1306044532
Name:COLLIS, ANGELIQUE DAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:DAWN
Last Name:COLLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 NE INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5544
Mailing Address - Country:US
Mailing Address - Phone:816-347-3232
Mailing Address - Fax:816-246-8207
Practice Address - Street 1:901 NE INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5544
Practice Address - Country:US
Practice Address - Phone:816-347-3232
Practice Address - Fax:816-246-8207
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010280891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO307F576COtherMEDICARE PERF. PROV. #