Provider Demographics
NPI:1396385936
Name:COLLIE, MICHEALE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:MICHEALE
Middle Name:
Last Name:COLLIE
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 NEW STATESIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-1165
Mailing Address - Country:US
Mailing Address - Phone:919-942-2803
Mailing Address - Fax:
Practice Address - Street 1:400 CRUTCHFIELD ST STE D
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2771
Practice Address - Country:US
Practice Address - Phone:919-251-8806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15467101YM0800X, 101YP2500X
NCLCAS-26102101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional