Healthcare Provider Details

I. General information

NPI: 1730479213
Provider Name (Legal Business Name): CARLY A.W. COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

V. Phone/Fax

Practice location:
  • Phone: 562-485-3098
  • Fax: 562-216-2337
Mailing address:
  • Phone: 562-485-3098
  • Fax: 562-216-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: