Provider Demographics
NPI:1811384241
Name:COLLINS, MARY (LPC-IT, CSAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LPC-IT, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20759 BURR OAK RD
Mailing Address - Street 2:
Mailing Address - City:CAPRON
Mailing Address - State:IL
Mailing Address - Zip Code:61012-9616
Mailing Address - Country:US
Mailing Address - Phone:815-482-2563
Mailing Address - Fax:
Practice Address - Street 1:20 S MAIN ST STE 21
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3959
Practice Address - Country:US
Practice Address - Phone:608-851-0348
Practice Address - Fax:815-737-8115
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16284-132101YA0400X
WI3943-226101YP2500X
WI7634-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078408Medicaid