Provider Demographics
NPI:1417799222
Name:COLLINS, DEANNE RUTH
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:RUTH
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEANNE
Other - Middle Name:RUTH
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3721 W TAPP RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3152
Mailing Address - Country:US
Mailing Address - Phone:812-929-3647
Mailing Address - Fax:
Practice Address - Street 1:3721 W TAPP RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3152
Practice Address - Country:US
Practice Address - Phone:812-929-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99105702A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health