Provider Demographics
NPI:1003386095
Name:COLLINS, CHANTANA B
Entity type:Individual
Prefix:
First Name:CHANTANA
Middle Name:B
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANTANA
Other - Middle Name:B
Other - Last Name:CHISM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:8933 SKYROCK CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1457
Mailing Address - Country:US
Mailing Address - Phone:443-468-1075
Mailing Address - Fax:
Practice Address - Street 1:8933 SKYROCK CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1457
Practice Address - Country:US
Practice Address - Phone:443-468-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician