Provider Demographics
NPI:1821504044
Name:COLLINS, KATRINA LANEEN
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LANEEN
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 1:1570 GELHOT DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-8356
Mailing Address - Country:US
Mailing Address - Phone:708-374-9372
Mailing Address - Fax:
Practice Address - Street 1:274 SUTTON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-3521
Practice Address - Country:US
Practice Address - Phone:513-231-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHYRP802M88649Medicaid