Provider Demographics
NPI:1184716466
Name:COLLINS, GARY G (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5790 MAGNOLIA AVE
Mailing Address - Street 2:STE. 202
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1874
Mailing Address - Country:US
Mailing Address - Phone:951-682-7240
Mailing Address - Fax:
Practice Address - Street 1:5790 MAGNOLIA AVE
Practice Address - Street 2:STE. 202
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1874
Practice Address - Country:US
Practice Address - Phone:951-682-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL5425103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical