Healthcare Provider Details

I. General information

NPI: 1306044532
Provider Name (Legal Business Name): ANGELIQUE DAWN COLLIS L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

IV. Provider business mailing address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-3232
  • Fax: 816-246-8207
Mailing address:
  • Phone: 816-347-3232
  • Fax: 816-246-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2001028089
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: