Provider Demographics
NPI:1104257625
Name:COLLINS, NATHANIEL III
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:COLLINS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 FONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3920
Mailing Address - Country:US
Mailing Address - Phone:702-561-3431
Mailing Address - Fax:
Practice Address - Street 1:1009 RUSTRIDGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6658
Practice Address - Country:US
Practice Address - Phone:855-239-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20131487332103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst