Provider Demographics
NPI:1255040051
Name:COLLINS, BRYAN JACOB
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JACOB
Last Name:COLLINS
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 1:420 N RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1133
Mailing Address - Country:US
Mailing Address - Phone:248-514-3784
Mailing Address - Fax:
Practice Address - Street 1:30880 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1000
Practice Address - Country:US
Practice Address - Phone:248-926-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 146L00000X, 156F00000X, 175M00000X, 171M00000X
MI228937373739171000000X
MI44352254678163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No171000000XOther Service ProvidersMilitary Health Care Provider
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No175M00000XOther Service ProvidersMidwife, Lay
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI33182311Medicaid