Healthcare Provider Details

I. General information

NPI: 1851819320
Provider Name (Legal Business Name): AMY JEAN COLLINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY JEAN GERO

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W 3RD ST
CONNERSVILLE IN
47331-1577
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-1164
  • Fax: 765-825-0215
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-741-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33008377A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009503A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: