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General NPI Number Information
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NPI Number | 1609391069
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Entity Type | Individual
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Provider Name | SAMANTHA COLLAZO
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Gender | Female
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Dates
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Enumeration Date | 08/07/2017
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Last Update Date | 01/18/2023
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Provider Practice Location Address
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Address Line | 907 MAR WALT DR STE 2021
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6756
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Country | US
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Telephone | 850-496-6923
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4111
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City | SHALIMAR
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State | FL
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Zip | 32579-4111
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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