Provider Demographics
NPI:1194346825
Name:COLLAZO, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 COUNTRY CLUB CT
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9268
Mailing Address - Country:US
Mailing Address - Phone:218-405-0321
Mailing Address - Fax:
Practice Address - Street 1:102 W KENWOOD AVE STE 120
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6380
Practice Address - Country:US
Practice Address - Phone:218-405-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015008101YM0800X
IL180.012952101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health