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General NPI Number Information
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NPI Number | 1063782423
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Entity Type | Individual
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Provider Name | ANGELA DENISE COLVILLE MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/03/2012
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Last Update Date | 10/24/2013
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Provider Practice Location Address
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Address Line | 1739 N WILMOT AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5523
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Country | US
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Telephone | 773-269-9400
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Fax | 269-912-5925
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Provider Business Mailing Address
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Address Line | 1739 N WILMOT AVE
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City | CHICAGO
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State | IL
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Zip | 60647-5523
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Country | US
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Telephone | 773-269-9400
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Fax | 269-912-5925
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 149013723
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License Number State | IL
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