Provider Demographics
NPI:1558147769
Name:COLLINS, NICOLE DANIELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
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 1:10755 E MEDINA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3212
Mailing Address - Country:US
Mailing Address - Phone:480-825-8285
Mailing Address - Fax:
Practice Address - Street 1:3925 E BROADWAY RD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-2977
Practice Address - Country:US
Practice Address - Phone:602-690-6901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 103TA0400X, 103K00000X, 103TB0200X, 103TC1900X, 103TP2701X, 251S00000X
MO2919083747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider