Provider Demographics
NPI:1295353902
Name:COLLINS, SARA DANISE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:DANISE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 E 34TH PL
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5602
Mailing Address - Country:US
Mailing Address - Phone:850-258-6904
Mailing Address - Fax:
Practice Address - Street 1:1247 RUCKER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3630
Practice Address - Country:US
Practice Address - Phone:334-347-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-123882106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician