Provider Demographics
NPI:1245865294
Name:COLLINS, RUSSIA JA'VON (LMHC)
Entity type:Individual
Prefix:
First Name:RUSSIA
Middle Name:JA'VON
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5802 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2541
Mailing Address - Country:US
Mailing Address - Phone:727-479-3054
Mailing Address - Fax:
Practice Address - Street 1:833 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-2250
Practice Address - Country:US
Practice Address - Phone:727-479-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH16538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH16538OtherLICENSED MENTAL HEALTH COUNSELOR