Provider Demographics
NPI:1770246803
Name:COLLINS, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:COLLINS
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 1:633 ACADEMY CIR SW
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-7426
Mailing Address - Country:US
Mailing Address - Phone:706-913-6304
Mailing Address - Fax:
Practice Address - Street 1:633 ACADEMY CIR SW
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-7426
Practice Address - Country:US
Practice Address - Phone:706-913-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty