Provider Demographics
NPI:1447883384
Name:SPECIALE, COLLIN
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:SPECIALE
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 1:6115 MOUNTAIN VILLA CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3518
Mailing Address - Country:US
Mailing Address - Phone:325-450-3014
Mailing Address - Fax:
Practice Address - Street 1:6115 MOUNTAIN VILLA CV
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3518
Practice Address - Country:US
Practice Address - Phone:325-450-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12614101YA0400X
TX73949101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)