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General NPI Number Information
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NPI Number | 1891124210
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Entity Type | Organization
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Legal Business Name | COLVILLE COUNSELING, LLC
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 11/06/2013
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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 |
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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 |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MRS. ANGELA DENISE COLVILLE
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Credential | LCSW
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Telephone | 773-269-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149013723
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License Number State | IL
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