Provider Demographics
NPI:1558630046
Name:COLGROVE, DOUG (MS, LSW)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:COLGROVE
Suffix:
Gender:M
Credentials:MS, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6745 GRAY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3262
Mailing Address - Country:US
Mailing Address - Phone:317-683-5078
Mailing Address - Fax:317-782-7905
Practice Address - Street 1:6745 GRAY RD
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3262
Practice Address - Country:US
Practice Address - Phone:317-683-5078
Practice Address - Fax:317-782-7905
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33003053A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor