Provider Demographics
NPI:1184318040
Name:COLLINS, ELISE ANDREA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:ANDREA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11314 WINN RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-4673
Mailing Address - Country:US
Mailing Address - Phone:813-541-1200
Mailing Address - Fax:
Practice Address - Street 1:9803 OLD SAINT AUGUSTINE RD STE 7
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8845
Practice Address - Country:US
Practice Address - Phone:855-203-7085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA22324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist