Provider Demographics
NPI:1669731972
Name:COLLABORATIVE PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:COLLABORATIVE PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GUNVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-292-3900
Mailing Address - Street 1:8961 W PALMETTO CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-5017
Mailing Address - Country:US
Mailing Address - Phone:414-536-8604
Mailing Address - Fax:414-536-8605
Practice Address - Street 1:6793 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3422
Practice Address - Country:US
Practice Address - Phone:414-292-3900
Practice Address - Fax:414-292-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI835-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty