Provider Demographics
NPI:1821675257
Name:ENGLENT, COLLIS I (MS)
Entity type:Individual
Prefix:MR
First Name:COLLIS
Middle Name:
Last Name:ENGLENT
Suffix:I
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10390 COLOMA RD STE A
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-2152
Mailing Address - Country:US
Mailing Address - Phone:877-910-6538
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4969
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-73911103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst