Provider Demographics
NPI:1952636706
Name:COLLINS, DAVID (LAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2018
Mailing Address - Country:US
Mailing Address - Phone:701-282-6561
Mailing Address - Fax:701-277-0306
Practice Address - Street 1:505 40TH ST S UNIT B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1184
Practice Address - Country:US
Practice Address - Phone:701-478-8440
Practice Address - Fax:701-478-8441
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1597101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)