Provider Demographics
NPI:1609027952
Name:IRELAND, COLEEN L (MFCC-I)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:L
Last Name:IRELAND
Suffix:
Gender:F
Credentials:MFCC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5708
Mailing Address - Country:US
Mailing Address - Phone:209-333-8778
Mailing Address - Fax:
Practice Address - Street 1:4545 9TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1452
Practice Address - Country:US
Practice Address - Phone:916-736-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist