Provider Demographics
NPI:1689002768
Name:COLVARD, INGRID LARRAINE (LICSW)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:LARRAINE
Last Name:COLVARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18606 NE 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-7137
Mailing Address - Country:US
Mailing Address - Phone:360-903-2645
Mailing Address - Fax:
Practice Address - Street 1:18606 NE 149TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-7137
Practice Address - Country:US
Practice Address - Phone:360-903-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW603980371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical