Provider Demographics
NPI:1659339307
Name:COLLIGAN, KEVIN MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:COLLIGAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 GUM BRANCH RD
Mailing Address - Street 2:STE 109
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:910-937-7171
Mailing Address - Fax:910-938-2556
Practice Address - Street 1:825 GUM BRANCH RD
Practice Address - Street 2:STE 109
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-937-7171
Practice Address - Fax:910-938-2556
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0028161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2868718Medicare ID - Type Unspecified
NC6002135Medicare ID - Type Unspecified