Provider Demographics
NPI:1770151888
Name:CEDERSTROM, COLLYTTE DIANA
Entity type:Individual
Prefix:
First Name:COLLYTTE
Middle Name:DIANA
Last Name:CEDERSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COLLYTTE
Other - Middle Name:DIANA
Other - Last Name:MEDDERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14 HAMILTONS BAY CT APT 506
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-9040
Mailing Address - Country:US
Mailing Address - Phone:803-242-2082
Mailing Address - Fax:
Practice Address - Street 1:609 S NEW HOPE RD STE 102
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4825
Practice Address - Country:US
Practice Address - Phone:704-208-1865
Practice Address - Fax:704-208-1865
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health