=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053897306
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER COLLINS SCHOOL PSY (WAIVER)
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 S GOLD ST
-----------------------------------------------------
City | YREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96097-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-842-8466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17506 GOPHER CT
-----------------------------------------------------
City | WEED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96094-9445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-598-4265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------