Provider Demographics
NPI:1881135291
Name:COLLINS, MARK (MSW, LSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E KIRKWOOD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-3559
Mailing Address - Country:US
Mailing Address - Phone:917-471-1784
Mailing Address - Fax:
Practice Address - Street 1:221 E KIRKWOOD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-3559
Practice Address - Country:US
Practice Address - Phone:917-471-1784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007901A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical