Provider Demographics
NPI:1124236443
Name:COLLEY, KATHLEEN PHYLLIS (MSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:PHYLLIS
Last Name:COLLEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20531 US HIGHWAY 75 SW
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-9045
Mailing Address - Country:US
Mailing Address - Phone:218-281-3351
Mailing Address - Fax:
Practice Address - Street 1:1407 24TH AVE S STE 217
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6761
Practice Address - Country:US
Practice Address - Phone:701-738-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN160801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical