MEDICARE: DEAVON LYNETTE COLLINS LPC-IT

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	101YM0800X	Mental Health Counselor	4259	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4259	OTHER	WI	LPC-IT

General Provider Information

NPI Number	:	1588125546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAVON LYNETTE COLLINS LPC-IT

Provider Business Mailing Address
First Line	:	4906 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2325
Country	:	US
Telephone Number	:	414-270-4670
Fax Number	:

Provider Business Practice Location Address
First Line	:	4906 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2325
Country	:	US
Telephone Number	:	414-270-4670
Fax Number	:

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

Provider Enumeration Date	:	03/30/2019
Last Update Date	:	03/30/2019

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