Provider Demographics
NPI:1285319814
Name:COLLINS, GRACE AUDRA
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:AUDRA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 S RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:MILBURN
Mailing Address - State:OK
Mailing Address - Zip Code:73450-1130
Mailing Address - Country:US
Mailing Address - Phone:580-387-9108
Mailing Address - Fax:
Practice Address - Street 1:6500 S RUSSELL RD
Practice Address - Street 2:
Practice Address - City:MILBURN
Practice Address - State:OK
Practice Address - Zip Code:73450-1130
Practice Address - Country:US
Practice Address - Phone:580-387-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health