Provider Demographics
NPI:1326108192
Name:COLLINS, MARIETTA (PH D)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WESTVIEW DRIVE SW
Mailing Address - Street 2:HARRIS BLDG., 100-A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-0000
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:
Practice Address - Street 1:455 LEE STREET SW
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310
Practice Address - Country:US
Practice Address - Phone:404-752-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0007744331AMedicaid
GA68BBFGXMedicare ID - Type Unspecified
GAS52760Medicare UPIN