Provider Demographics
NPI:1003397068
Name:COLLIAS, MICK GENE
Entity type:Individual
Prefix:
First Name:MICK
Middle Name:GENE
Last Name:COLLIAS
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 1:1301 N ELM ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1140
Mailing Address - Country:US
Mailing Address - Phone:636-359-8140
Mailing Address - Fax:
Practice Address - Street 1:1003 COTTONWOOD RD
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1012
Practice Address - Country:US
Practice Address - Phone:641-782-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health