Provider Demographics
NPI:1265938674
Name:COLLINS, GENE HENRY (EDS NCSP)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:HENRY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:EDS NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-1127
Mailing Address - Country:US
Mailing Address - Phone:276-926-4643
Mailing Address - Fax:276-926-5597
Practice Address - Street 1:309 VOLUNTEER AVENUE
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228-1127
Practice Address - Country:US
Practice Address - Phone:276-926-4643
Practice Address - Fax:276-926-5597
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000075103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty