Provider Demographics
NPI:1396188454
Name:COLLINS, SHA-VONN
Entity Type:Individual
Prefix:
First Name:SHA-VONN
Middle Name:
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 1:170 E KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1629
Mailing Address - Country:US
Mailing Address - Phone:775-934-6043
Mailing Address - Fax:
Practice Address - Street 1:822 AITKEN ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1314
Practice Address - Country:US
Practice Address - Phone:759-346-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8317-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker