Provider Demographics
NPI:1588000723
Name:NULL, COLLEEN ELIZABETH (LISW-S)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:NULL
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:ZYCHOWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3815
Mailing Address - Fax:419-383-2930
Practice Address - Street 1:1400 E MEDICAL LOOP
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614
Practice Address - Country:US
Practice Address - Phone:419-383-3815
Practice Address - Fax:419-383-2930
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0094631041C0700X
OHI.16000111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0178495Medicaid