Provider Demographics
NPI:1124211578
Name:PETERS, COLIN JAMES I (LCSW)
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:JAMES
Last Name:PETERS
Suffix:I
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:COLIN
Other - Middle Name:JAMES
Other - Last Name:PETERS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2709 N MONTICELLO AVE # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1131
Mailing Address - Country:US
Mailing Address - Phone:773-960-4282
Mailing Address - Fax:
Practice Address - Street 1:6550 N. TALMAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-5323
Practice Address - Country:US
Practice Address - Phone:773-960-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18305101YA0400X
IL149.0123561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)