Provider Demographics
NPI:1760678031
Name:COLIBRI, ANGELICA MARINA LUCCIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:MARINA LUCCIA
Last Name:COLIBRI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1578
Mailing Address - Country:US
Mailing Address - Phone:847-903-5604
Mailing Address - Fax:
Practice Address - Street 1:7831 S SCEPTER DR APT 6
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-2267
Practice Address - Country:US
Practice Address - Phone:414-331-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7618-123101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760678031Medicaid