Provider Demographics
NPI:1487144945
Name:COLLINS, GEORGETTEA M
Entity type:Individual
Prefix:
First Name:GEORGETTEA
Middle Name:M
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:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-0226
Mailing Address - Country:US
Mailing Address - Phone:740-947-6727
Mailing Address - Fax:
Practice Address - Street 1:1311 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4602
Practice Address - Country:US
Practice Address - Phone:740-354-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHQMHS101YM0800X
OHCDCA.171326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0305672Medicaid