Provider Demographics
NPI:1649608191
Name:COLLINS CLINICAL GROUP, P.C.
Entity type:Organization
Organization Name:COLLINS CLINICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:312-399-9601
Mailing Address - Street 1:4433 N RAVENSWOOD AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7755
Mailing Address - Country:US
Mailing Address - Phone:312-399-9601
Mailing Address - Fax:773-944-1057
Practice Address - Street 1:4433 N RAVENSWOOD AVE STE 210
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-7755
Practice Address - Country:US
Practice Address - Phone:312-399-9601
Practice Address - Fax:773-944-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty