Provider Demographics
NPI:1639107329
Name:COLLINS, GARY TYRONE (MSW, LPC, CCAC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:TYRONE
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MSW, LPC, CCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-425-9541
Mailing Address - Fax:304-425-1332
Practice Address - Street 1:787 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2341
Practice Address - Country:US
Practice Address - Phone:304-436-2106
Practice Address - Fax:304-436-6362
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV02-322101YA0400X
WV1528101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health