Provider Demographics
NPI:1841597564
Name:COLLINS, ZACHARY ROSELLO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:ROSELLO
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MT. BELVEDERE BLVD
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-6703
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MT. BELVEDERE BLVD
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical