Healthcare Provider Details

I. General information

NPI: 1780330829
Provider Name (Legal Business Name): COLIN MICHAEL IWANSKI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 REGENCY PKWY STE 285
CARY NC
27518-8506
US

IV. Provider business mailing address

2000 REGENCY PKWY STE 285
CARY NC
27518-8506
US

V. Phone/Fax

Practice location:
  • Phone: 919-234-6144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number103468
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: