Provider Demographics
NPI:1548230956
Name:WAXLER, COLLEEN MARIE (MA LPC MH LMFT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARIE
Last Name:WAXLER
Suffix:
Gender:F
Credentials:MA LPC MH LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702
Mailing Address - Country:US
Mailing Address - Phone:605-341-8647
Mailing Address - Fax:605-341-0489
Practice Address - Street 1:3601 CANYON LAKE DR
Practice Address - Street 2:CHRYSALIS
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702
Practice Address - Country:US
Practice Address - Phone:605-341-8647
Practice Address - Fax:605-341-0489
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2022101Y00000X
SD1080106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575172Medicaid