Provider Demographics
NPI:1427341528
Name:COLLINS, PORSCHE RENNA (LCSW)
Entity type:Individual
Prefix:MS
First Name:PORSCHE
Middle Name:RENNA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12868 CLYDESDALE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28107-7825
Mailing Address - Country:US
Mailing Address - Phone:203-430-7551
Mailing Address - Fax:
Practice Address - Street 1:769 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1118
Practice Address - Country:US
Practice Address - Phone:704-376-7180
Practice Address - Fax:704-531-9266
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0075711041C0700X
CT0070891041C0700X
IN34009362A1041C0700X
SC118171041C0700X
GACSW0058021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106339Medicaid