Provider Demographics
NPI:1760540835
Name:KOLLBERG, MARY COLLEEN (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:KOLLBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:KOLLBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:130 2ND ST
Mailing Address - Street 2:4-SOUTH
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2883
Mailing Address - Country:US
Mailing Address - Phone:920-729-2151
Mailing Address - Fax:
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:4-SOUTH
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-729-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1426104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIQ36787Medicare UPIN