Healthcare Provider Details

I. General information

NPI: 1699181289
Provider Name (Legal Business Name): DEMETRIA COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CHARLESTON BLVD STE 130
LAS VEGAS NV
89104-6681
US

IV. Provider business mailing address

1401 N MICHAEL WAY APT 148
LAS VEGAS NV
89108-1460
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-5059
  • Fax:
Mailing address:
  • Phone: 702-480-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIC-1138
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: