=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790235703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANICE COLLINS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 10/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12N393 WAUGHON RD
-----------------------------------------------------
City | HAMPSHIRE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60140-8426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-983-3773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 VILLAGE DR APT 349
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60004-8122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-983-3773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150015582
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------