Provider Demographics
NPI:1689256026
Name:COLLAZO, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 NW 77TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-5241
Mailing Address - Country:US
Mailing Address - Phone:786-300-7704
Mailing Address - Fax:
Practice Address - Street 1:3525 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4015
Practice Address - Country:US
Practice Address - Phone:305-642-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health