Provider Demographics
NPI:1861144883
Name:COLLI, VICTOR JESUS
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:JESUS
Last Name:COLLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25910 ACERO STE 160
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2777
Mailing Address - Country:US
Mailing Address - Phone:714-640-1566
Mailing Address - Fax:
Practice Address - Street 1:9091 CALADIUM AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1418
Practice Address - Country:US
Practice Address - Phone:714-438-9603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician