Healthcare Provider Details

I. General information

NPI: 1780405563
Provider Name (Legal Business Name): MELANIE COLLAZO MS, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22790 SW 112TH AVE
MIAMI FL
33170-7602
US

IV. Provider business mailing address

15275 SW 89TH TER
MIAMI FL
33196-1469
US

V. Phone/Fax

Practice location:
  • Phone: 305-235-2616
  • Fax: 305-235-6178
Mailing address:
  • Phone: 305-281-8684
  • Fax:

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: