=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184988073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLIER PSYCHOLOGICAL SERVICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2012
-----------------------------------------------------
Last Update Date | 06/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8015 W KENTON CIR SUITE 150
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-997-6212
-----------------------------------------------------
Fax | 704-997-6216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8015 W KENTON CIR SUITE 150
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-997-6212
-----------------------------------------------------
Fax | 704-997-6216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MISTY L. COLLIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-997-6212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2538
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------