Provider Demographics
NPI:1164213203
Name:COLLAZO, IDAMARIE (LSW)
Entity type:Individual
Prefix:
First Name:IDAMARIE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:IDA MARIE
Other - Middle Name:
Other - Last Name:MARTINEZ COLLAZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3603 WASHINGTON BLVD APT 101
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3572
Mailing Address - Country:US
Mailing Address - Phone:317-643-0288
Mailing Address - Fax:
Practice Address - Street 1:927 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1020
Practice Address - Country:US
Practice Address - Phone:833-659-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33012643A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker