Provider Demographics
NPI:1013522846
Name:COLLAZO, MIRIAM DAMARIS
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:DAMARIS
Last Name:COLLAZO
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 1:405 GROVE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1270
Mailing Address - Country:US
Mailing Address - Phone:617-862-2196
Mailing Address - Fax:617-862-2196
Practice Address - Street 1:405 GROVE ST STE 201
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1270
Practice Address - Country:US
Practice Address - Phone:617-862-2196
Practice Address - Fax:617-862-2196
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MALMHC10000359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health