Provider Demographics
NPI:1851898530
Name:COLLINS, JOHN M
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:COLLINS
Suffix:
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 1:720 W BROADWAY STE 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3245
Mailing Address - Country:US
Mailing Address - Phone:502-561-0943
Mailing Address - Fax:502-561-0944
Practice Address - Street 1:351 BURLEY AVE STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1011
Practice Address - Country:US
Practice Address - Phone:859-402-8224
Practice Address - Fax:859-523-0226
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid