Provider Demographics
NPI:1629534243
Name:WHAM, COLLEEN MADDEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MADDEN
Last Name:WHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 VALLEY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-2468
Mailing Address - Country:US
Mailing Address - Phone:215-285-0445
Mailing Address - Fax:
Practice Address - Street 1:188 VALLEY ST STE 201
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-2468
Practice Address - Country:US
Practice Address - Phone:215-285-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional