Provider Demographics
NPI:1679312888
Name:COLLINS, THERESA (LCPC C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LCPC C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FARWELL ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 FARWELL ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ME
Practice Address - Zip Code:04250-6824
Practice Address - Country:US
Practice Address - Phone:207-353-8118
Practice Address - Fax:207-407-1209
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL7399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health