Provider Demographics
NPI:1902401714
Name:COLLAZO, JUSTINE (LMFT)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 MAPLE AVE APT 49
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7125
Mailing Address - Country:US
Mailing Address - Phone:310-626-3854
Mailing Address - Fax:
Practice Address - Street 1:18000 STUDEBAKER RD STE 700
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2684
Practice Address - Country:US
Practice Address - Phone:310-864-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119202106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty