Provider Demographics
NPI:1851689921
Name:COLLAZOS, BERTHA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:COLLAZOS
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 1:6875 COLLEGE CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7164
Mailing Address - Country:US
Mailing Address - Phone:954-593-8319
Mailing Address - Fax:
Practice Address - Street 1:12401 ORANGE DR
Practice Address - Street 2:SUITE 219
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4341
Practice Address - Country:US
Practice Address - Phone:954-862-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001298400Medicaid