Provider Demographics
NPI:1154551422
Name:COLLETTE, ROBERT (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:COLLETTE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 CAMINO LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5825
Mailing Address - Country:US
Mailing Address - Phone:928-453-0222
Mailing Address - Fax:
Practice Address - Street 1:12302 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7833
Practice Address - Country:US
Practice Address - Phone:928-669-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12469104100000X
MO20020300461041C0700X
CO1251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker