Provider Demographics
NPI:1447747233
Name:COLLINS, KARISSA J (MFT I88089)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MFT I88089
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4015
Mailing Address - Country:US
Mailing Address - Phone:714-330-9695
Mailing Address - Fax:
Practice Address - Street 1:17111 BEACH BLVD STE 205
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5947
Practice Address - Country:US
Practice Address - Phone:714-654-1570
Practice Address - Fax:844-533-6952
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81-4091538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health