Provider Demographics
NPI:1639478076
Name:COLEGROVE, BERNADETTE
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:COLEGROVE
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 1:3388 NAPA BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-4506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD.
Practice Address - Street 2:
Practice Address - City:SHAKER-HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118
Practice Address - Country:US
Practice Address - Phone:216-320-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0027942104100000X
OHS 0027942104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker