Healthcare Provider Details

I. General information

NPI: 1952807182
Provider Name (Legal Business Name): KEISHA R. COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MANSFIELD AVE
SHELBY OH
44875-1832
US

IV. Provider business mailing address

169 MANSFIELD AVE
SHELBY OH
44875-1832
US

V. Phone/Fax

Practice location:
  • Phone: 567-292-9211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2103532-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: