Provider Demographics
NPI:1114948221
Name:HEBERT, COLLEEN S (OD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:S
Last Name:HEBERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 REENA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3145
Mailing Address - Country:US
Mailing Address - Phone:920-563-8468
Mailing Address - Fax:920-563-7018
Practice Address - Street 1:740 REENA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3145
Practice Address - Country:US
Practice Address - Phone:920-563-8468
Practice Address - Fax:920-563-7018
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2429-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114948221Medicaid
WI1114948221Medicaid
WIK400177198Medicare PIN
WI60936OtherDEAN HEALTH INSURANCE