Provider Demographics
NPI:1396259222
Name:COLLINS, ILENE
Entity type:Individual
Prefix:MS
First Name:ILENE
Middle Name:
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 1:302 CHERRY LN STE 201
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4311
Mailing Address - Country:US
Mailing Address - Phone:646-241-8841
Mailing Address - Fax:
Practice Address - Street 1:302 CHERRY LN STE 201
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:209-478-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No253J00000XAgenciesFoster Care Agency