Basic Information
| Provider Information | |||||||||
| NPI: | 1326108192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | MARIETTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DRIVE SW | ||||||||
| Address2: | HARRIS BLDG., 100-A | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303100000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 LEE STREET SW | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047521000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY002127 | GA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0007744331A | 05 | GA | MEDICAID |