Provider Demographics
NPI:1619667573
Name:COLLINS, ANGELIQUE ALEXIS (CAC-AD)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:ALEXIS
Last Name:COLLINS
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N EUTAW ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4648
Mailing Address - Country:US
Mailing Address - Phone:410-225-9185
Mailing Address - Fax:410-225-7964
Practice Address - Street 1:821 N EUTAW ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4648
Practice Address - Country:US
Practice Address - Phone:410-225-9185
Practice Address - Fax:410-225-7964
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2837101YA0400X, 101YP2500X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional