Provider Demographics
NPI:1417973132
Name:COLLINS, MARY ALICE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 MONTEMAR WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5549
Mailing Address - Country:US
Mailing Address - Phone:408-979-0660
Mailing Address - Fax:408-979-0660
Practice Address - Street 1:1739 MONTEMAR WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5549
Practice Address - Country:US
Practice Address - Phone:408-979-0660
Practice Address - Fax:408-979-0660
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT15189106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist