Healthcare Provider Details

I. General information

NPI: 1972775229
Provider Name (Legal Business Name): ELIZABETH AMANDA COLLIER CSAC,ICS,LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 N GRANDVIEW BLVD #104, #102
WAUKESHA WI
53188-1686
US

IV. Provider business mailing address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209-1220
US

V. Phone/Fax

Practice location:
  • Phone: 262-446-9981
  • Fax:
Mailing address:
  • Phone: 414-540-2170
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14970-132
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8135
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: