Provider Demographics
NPI:1578259982
Name:COLLINSWORTH, MICHAEL DAVID
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:COLLINSWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1798
Mailing Address - Country:US
Mailing Address - Phone:678-548-2036
Mailing Address - Fax:
Practice Address - Street 1:4139 BAKER ST NE STE 16
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1409
Practice Address - Country:US
Practice Address - Phone:678-532-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health