Provider Demographics
NPI:1679091649
Name:COLLINS, SHADE SHAMARION
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:SHAMARION
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 1:51 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-1901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 COUNTRY CLUB DROVE
Practice Address - Street 2:
Practice Address - City:LAPLACE
Practice Address - State:LA
Practice Address - Zip Code:70068
Practice Address - Country:US
Practice Address - Phone:504-602-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health