Provider Demographics
NPI:1811404437
Name:COLLINS, MONTIQUE S
Entity Type:Individual
Prefix:
First Name:MONTIQUE
Middle Name:S
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 1:3620 W GLENDALE AVE
Mailing Address - Street 2:16
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051
Mailing Address - Country:US
Mailing Address - Phone:602-455-4626
Mailing Address - Fax:602-455-4624
Practice Address - Street 1:729 W MALDONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6763
Practice Address - Country:US
Practice Address - Phone:602-455-4626
Practice Address - Fax:602-455-2624
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6439857385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child