Provider Demographics
NPI:1629327580
Name:COLLINS, MARA BLYTHE (LMFT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:BLYTHE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 KIMMERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30344-6809
Mailing Address - Country:US
Mailing Address - Phone:678-938-7677
Mailing Address - Fax:
Practice Address - Street 1:1189 EUCLID AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1509
Practice Address - Country:US
Practice Address - Phone:404-522-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001258106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist