MEDICARE: LISA MARIE COLLINGWOOD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3031	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8D4562	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P00246197	OTHER	TX	RAILROAD

General Provider Information

NPI Number	:	1134158751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE COLLINGWOOD PHD

Provider Business Mailing Address
First Line	:	1337 S CESAR E CHAVEZ DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-2712
Country	:	US
Telephone Number	:	414-897-5511
Fax Number	:	414-385-7552

Provider Business Practice Location Address
First Line	:	8204 ELMBROOK DR
Second Line	:	SUITE 360
City	:	DALLAS
State	:	TX
Zip	:	75247-4067
Country	:	US
Telephone Number	:	214-219-0780
Fax Number	:	214-219-0782

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	06/25/2018

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