Provider Demographics
NPI:1437744869
Name:COLLINS, MARK THOMAS (MA, LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MA, LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:MN
Mailing Address - Zip Code:55357-0308
Mailing Address - Country:US
Mailing Address - Phone:763-479-3555
Mailing Address - Fax:763-479-2605
Practice Address - Street 1:3675 IHDUHAPI RD
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:MN
Practice Address - Zip Code:55357-2120
Practice Address - Country:US
Practice Address - Phone:763-479-3555
Practice Address - Fax:763-479-2605
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health