Provider Demographics
NPI:1851695134
Name:COLLAZO, SIMON III
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:COLLAZO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9445 FARNHAM ST
Mailing Address - Street 2:SUIT 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:619-380-4661
Mailing Address - Fax:
Practice Address - Street 1:9445 FARNHAM ST
Practice Address - Street 2:SUIT 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1308
Practice Address - Country:US
Practice Address - Phone:619-380-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health