Provider Demographics
NPI:1215795885
Name:COLLINS, DIETMAR
Entity type:Individual
Prefix:
First Name:DIETMAR
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DJ
Other - Middle Name:
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:429 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7064
Mailing Address - Country:US
Mailing Address - Phone:405-275-1844
Mailing Address - Fax:
Practice Address - Street 1:429 N UNION AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-7064
Practice Address - Country:US
Practice Address - Phone:405-275-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20739-P101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor