Healthcare Provider Details

I. General information

NPI: 1073682647
Provider Name (Legal Business Name): KELLY S COLLINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E 101ST ST
NEW YORK NY
10029-6106
US

IV. Provider business mailing address

303 GEORGE ST
NEW BRUNSWICK NJ
08901-2020
US

V. Phone/Fax

Practice location:
  • Phone: 212-534-8596
  • Fax: 212-860-8407
Mailing address:
  • Phone: 732-235-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071606R
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05435700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: