Provider Demographics
NPI:1720109762
Name:COLLARD, MARGUERITE KIM (MA)
Entity type:Individual
Prefix:MRS
First Name:MARGUERITE
Middle Name:KIM
Last Name:COLLARD
Suffix:
Gender:F
Credentials:MA
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 4048
Mailing Address - Street 2:#44 KATHLEEN DR
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88062-4048
Mailing Address - Country:US
Mailing Address - Phone:505-574-2324
Mailing Address - Fax:
Practice Address - Street 1:44 KATHLEEN DR
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-9133
Practice Address - Country:US
Practice Address - Phone:505-574-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0701101Y00000X, 101YM0800X
NM229357101YS0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00G6406Medicaid