Provider Demographics
NPI:1376881086
Name:COLLINS, MARK A (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BEACH 80TH ST
Mailing Address - Street 2:APT 3C
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 BEACH 80TH ST
Practice Address - Street 2:APT 3C
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-2002
Practice Address - Country:US
Practice Address - Phone:718-474-0539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor