Healthcare Provider Details

I. General information

NPI: 1134958507
Provider Name (Legal Business Name): CONREDGE COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 FULTON INDUSTRIAL BLVD NW
ATLANTA GA
30336
US

IV. Provider business mailing address

2318 GREENSIDE DR
AUSTELL GA
30106-8248
US

V. Phone/Fax

Practice location:
  • Phone: 404-346-3471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: