Provider Demographics
NPI:1386017754
Name:COLLMANN, JUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:COLLMANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 PRUNETREE CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4984
Mailing Address - Country:US
Mailing Address - Phone:707-536-6956
Mailing Address - Fax:
Practice Address - Street 1:435 PETALUMA AVE
Practice Address - Street 2:SUITE 110E
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4277
Practice Address - Country:US
Practice Address - Phone:707-536-6956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27539103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral