Healthcare Provider Details

I. General information

NPI: 1376200048
Provider Name (Legal Business Name): COLLECTIVE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W JACKSON ST STE 104
DUBLIN GA
31021-6169
US

IV. Provider business mailing address

2035 REBIE RD
DUDLEY GA
31022-2411
US

V. Phone/Fax

Practice location:
  • Phone: 478-595-0317
  • Fax: 888-249-2172
Mailing address:
  • Phone: 478-595-0317
  • Fax: 888-249-2172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HOLLY MCDONALD HOWARD
Title or Position: OWNER/SLP
Credential: M.ED., CCC-SLP
Phone: 478-595-0317