Provider Demographics
NPI:1144955527
Name:YVONNE COLLINS LICENSED CLINICAL SOCIAL WORKER PC
Entity type:Organization
Organization Name:YVONNE COLLINS LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:909-204-9992
Mailing Address - Street 1:154 W FOOTHILL BLVD.
Mailing Address - Street 2:A-158
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-204-9992
Mailing Address - Fax:909-204-2820
Practice Address - Street 1:9431 HAVEN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCUAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-204-9992
Practice Address - Fax:909-204-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1063959054Medicaid