Provider Demographics
NPI:1316400914
Name:COLLACOTT, COLETTE KAITLYN
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:KAITLYN
Last Name:COLLACOTT
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 1:37 SCRIPTER CT
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4787
Mailing Address - Country:US
Mailing Address - Phone:586-596-6094
Mailing Address - Fax:
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
68011109201041C0700X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical