Provider Demographics
NPI:1659730539
Name:FOOTE-DERANGO, COLLEEN LOUISE (MA, LISAC, SEP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LOUISE
Last Name:FOOTE-DERANGO
Suffix:
Gender:F
Credentials:MA, LISAC, SEP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:LOUISE
Other - Last Name:DERANGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LISAC, SEP
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:YARNELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85362-0564
Mailing Address - Country:US
Mailing Address - Phone:928-231-2006
Mailing Address - Fax:
Practice Address - Street 1:16724 WILLOW AVE.
Practice Address - Street 2:
Practice Address - City:YARNELL
Practice Address - State:AZ
Practice Address - Zip Code:85362
Practice Address - Country:US
Practice Address - Phone:928-231-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
AZLISAC-11512101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health