Healthcare Provider Details

I. General information

NPI: 1225690555
Provider Name (Legal Business Name): KRISTA RAE COLLINSON CDCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N BINKLEY ST STE 202
SOLDOTNA AK
99669-7500
US

IV. Provider business mailing address

PO BOX 2070
KENAI AK
99611
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4521
  • Fax:
Mailing address:
  • Phone: 907-953-4749
  • Fax: 907-260-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4586
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: