Healthcare Provider Details

I. General information

NPI: 1619667573
Provider Name (Legal Business Name): ANGELIQUE ALEXIS COLLINS CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N EUTAW ST
BALTIMORE MD
21201-4648
US

IV. Provider business mailing address

821 N EUTAW ST
BALTIMORE MD
21201-4648
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-9185
  • Fax: 410-225-7964
Mailing address:
  • Phone: 410-225-9185
  • Fax: 410-225-7964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC2837
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAC2837
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberAC2837
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: