Provider Demographics
NPI:1609969781
Name:COLEGROVE, ROBERT WRIGHT JR (EDD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WRIGHT
Last Name:COLEGROVE
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15409 DICKENS ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3009
Mailing Address - Country:US
Mailing Address - Phone:818-986-4362
Mailing Address - Fax:818-986-9263
Practice Address - Street 1:15409 DICKENS ST
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3009
Practice Address - Country:US
Practice Address - Phone:818-986-4362
Practice Address - Fax:818-986-9263
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10862103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10862Medicare ID - Type Unspecified