Provider Demographics
NPI:1568873289
Name:COLLINS-DUNHAM, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:COLLINS-DUNHAM
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 1:1340 ABRAM DR
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866-3485
Mailing Address - Country:US
Mailing Address - Phone:757-358-0032
Mailing Address - Fax:
Practice Address - Street 1:1340 ABRAM DR
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-3485
Practice Address - Country:US
Practice Address - Phone:757-358-0032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker