Healthcare Provider Details

I. General information

NPI: 1700472180
Provider Name (Legal Business Name): COLL COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 N 67TH AVE UNIT 1109
PHOENIX AZ
85033-1670
US

IV. Provider business mailing address

4545 N 67TH AVE UNIT 1109
PHOENIX AZ
85033-1670
US

V. Phone/Fax

Practice location:
  • Phone: 954-544-9065
  • Fax:
Mailing address:
  • Phone: 954-544-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: COLLINS KUKWA AYEAH
Title or Position: ADMINISTRATOR
Credential:
Phone: 954-544-9065