Healthcare Provider Details

I. General information

NPI: 1619219532
Provider Name (Legal Business Name): CHERYL ELIZABETH COLWIN SAC-IT/PLC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 FOND DU LAC AVENUE
KEWASKUM WI
53040
US

IV. Provider business mailing address

1421 FOND DU LAC AVENUE
KEWASKUM WI
53040
US

V. Phone/Fax

Practice location:
  • Phone: 262-626-4166
  • Fax: 262-626-8431
Mailing address:
  • Phone: 262-626-4166
  • Fax: 262-626-8431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberDHS75.14#2598
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: