Healthcare Provider Details

I. General information

NPI: 1619667573
Provider Name (Legal Business Name): ANGELIQUE ALEXIS COLLINS LCA3591
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HAWK RISE LN
OWINGS MILLS MD
21117-4998
US

IV. Provider business mailing address

137 COLLINS AVE
BALTIMORE MD
21229-3604
US

V. Phone/Fax

Practice location:
  • Phone: 443-500-2035
  • Fax:
Mailing address:
  • Phone: 443-500-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA3591
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: