Provider Demographics
NPI:1619684776
Name:COLLINS, TRACEY S
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
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 1:2345 W OLD 101 RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:IN
Mailing Address - Zip Code:47353-9392
Mailing Address - Country:US
Mailing Address - Phone:513-720-3056
Mailing Address - Fax:
Practice Address - Street 1:2345 W OLD 101 RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:IN
Practice Address - Zip Code:47353-9392
Practice Address - Country:US
Practice Address - Phone:513-720-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0008550104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker