Provider Demographics
NPI:1407474992
Name:COLLINS, CHARLENE RENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:RENE
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 1:4300 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-4006
Mailing Address - Country:US
Mailing Address - Phone:352-374-5600
Mailing Address - Fax:352-224-2471
Practice Address - Street 1:4300 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-4006
Practice Address - Country:US
Practice Address - Phone:352-374-5600
Practice Address - Fax:352-224-2471
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLMT3979106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor