Provider Demographics
NPI:1194297424
Name:COLLINS, DIVVIA-CLYNE ASHLEY (BCABA)
Entity type:Individual
Prefix:
First Name:DIVVIA-CLYNE
Middle Name:ASHLEY
Last Name:COLLINS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 LEONE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4079
Mailing Address - Country:US
Mailing Address - Phone:386-679-4554
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-17-7834106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018980700Medicaid