Provider Demographics
NPI:1912904400
Name:COLLERAN, MICHAEL J (MA, CCC-A)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:COLLERAN
Suffix:
Gender:M
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-3368
Mailing Address - Country:US
Mailing Address - Phone:605-224-8848
Mailing Address - Fax:605-224-7870
Practice Address - Street 1:633 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3368
Practice Address - Country:US
Practice Address - Phone:605-224-8848
Practice Address - Fax:605-224-7870
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD33001460445192EUT001231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD58301321Medicaid
SD2791Medicare ID - Type UnspecifiedOFFICE MEDICARE NUMBER
SD68002Medicare ID - Type UnspecifiedPERSONAL