Healthcare Provider Details

I. General information

NPI: 1124933023
Provider Name (Legal Business Name): MR. ANDREW LEE COLLINS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 W MARQUETTE RD
CHICAGO IL
60636-2539
US

IV. Provider business mailing address

2209 W MARQUETTE RD
CHICAGO IL
60636-2539
US

V. Phone/Fax

Practice location:
  • Phone: 773-630-4494
  • Fax:
Mailing address:
  • Phone: 773-630-4494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberC452-0126-1030
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: