Provider Demographics
NPI:1689369225
Name:COLLAZO, NICOLAS RAFAEL SR
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:RAFAEL
Last Name:COLLAZO
Suffix:SR
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 1:818 SW 2ND ST APT 304
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-1246
Mailing Address - Country:US
Mailing Address - Phone:305-833-1643
Mailing Address - Fax:
Practice Address - Street 1:818 SW 2ND ST APT 304
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-1246
Practice Address - Country:US
Practice Address - Phone:305-833-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-267541106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician