Provider Demographics
NPI:1104228642
Name:COLLINS, TIMOTHY R (LISW-S)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27391 DETROIT RD
Mailing Address - Street 2:APT C34
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2278
Mailing Address - Country:US
Mailing Address - Phone:216-647-1941
Mailing Address - Fax:
Practice Address - Street 1:3929 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4153
Practice Address - Country:US
Practice Address - Phone:216-252-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2103188101YM0800X, 1041C0700X
OHS 1450685104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker