Provider Demographics
NPI:1508300518
Name:COLLINS, BLAKE-ALEXANDRIA ALEXIS (BA, SUDRC)
Entity Type:Individual
Prefix:MS
First Name:BLAKE-ALEXANDRIA
Middle Name:ALEXIS
Last Name:COLLINS
Suffix:
Gender:F
Credentials:BA, SUDRC
Other - Prefix:MRS
Other - First Name:ALEXANDRIA
Other - Middle Name:
Other - Last Name:COLLINS-WISNIOWSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDRC
Mailing Address - Street 1:119 ROBINSON LN
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2351
Mailing Address - Country:US
Mailing Address - Phone:831-760-2774
Mailing Address - Fax:
Practice Address - Street 1:1015 NW 56TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4481
Practice Address - Country:US
Practice Address - Phone:352-835-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16901101YA0400X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009093700Medicaid