Provider Demographics
NPI:1275871865
Name:COLEGROVE, RACHELLE L
Entity Type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:L
Last Name:COLEGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 S EASTGATE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-2146
Mailing Address - Country:US
Mailing Address - Phone:417-763-3309
Mailing Address - Fax:
Practice Address - Street 1:2131 S EASTGATE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-2146
Practice Address - Country:US
Practice Address - Phone:417-763-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional