Provider Demographics
NPI:1063782423
Name:COLVILLE, ANGELA DENISE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:DENISE
Last Name:COLVILLE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 N WILMOT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5523
Mailing Address - Country:US
Mailing Address - Phone:773-269-9400
Mailing Address - Fax:269-912-5925
Practice Address - Street 1:1739 N WILMOT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5523
Practice Address - Country:US
Practice Address - Phone:773-269-9400
Practice Address - Fax:269-912-5925
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149013723101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional