Provider Demographics
NPI:1326688219
Name:COLLINS, ANJELICA JADE
Entity Type:Individual
Prefix:
First Name:ANJELICA
Middle Name:JADE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 POTRERO ST STE 42-103
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2779
Mailing Address - Country:US
Mailing Address - Phone:831-466-9307
Mailing Address - Fax:
Practice Address - Street 1:1630 COBBLESTONE CT
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-6744
Practice Address - Country:US
Practice Address - Phone:408-612-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21907225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA116OtherOCCUPATIONAL THERAPY