Provider Demographics
NPI:1790065175
Name:VANSLAMBROUCK, COLLEEN BULLARD (LMSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:BULLARD
Last Name:VANSLAMBROUCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8575 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9409
Mailing Address - Country:US
Mailing Address - Phone:269-375-0372
Mailing Address - Fax:
Practice Address - Street 1:8575 2ND ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9409
Practice Address - Country:US
Practice Address - Phone:269-375-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010198741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical