Provider Demographics
NPI:1033294947
Name:COLSTON, LARRY WILLIS (LMSW,ACSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WILLIS
Last Name:COLSTON
Suffix:
Gender:M
Credentials:LMSW,ACSW
Other - Prefix:MR
Other - First Name:LARRY
Other - Middle Name:WILLIS
Other - Last Name:COLSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW,ACSW
Mailing Address - Street 1:10 PETERBORO ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2722
Mailing Address - Country:US
Mailing Address - Phone:313-831-3160
Mailing Address - Fax:313-831-2604
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:313-831-2604
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010340961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical