Healthcare Provider Details

I. General information

NPI: 1780627935
Provider Name (Legal Business Name): CAROL ANN COLLINS ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 N LEROUX ST
FLAGSTAFF AZ
86001-3221
US

IV. Provider business mailing address

123 S SAN FRANCISCO ST SUITE 12
FLAGSTAFF AZ
86001-5796
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-2581
  • Fax: 928-774-2581
Mailing address:
  • Phone: 928-774-2581
  • Fax: 928-773-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: