Provider Demographics
NPI:1528209590
Name:COLQUITT, IDA VERONICA (LLP)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:VERONICA
Last Name:COLQUITT
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-478-8233
Mailing Address - Fax:734-544-6726
Practice Address - Street 1:555 TOWNER ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5752
Practice Address - Country:US
Practice Address - Phone:734-478-8233
Practice Address - Fax:734-544-6726
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist