Provider Demographics
NPI:1316453624
Name:COLEGROVE, DANIEL CLAUDE (LSW)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CLAUDE
Last Name:COLEGROVE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 VINEYARD DR APT 404
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-3350
Mailing Address - Country:US
Mailing Address - Phone:440-665-5260
Mailing Address - Fax:
Practice Address - Street 1:312 3RD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5618
Practice Address - Country:US
Practice Address - Phone:440-323-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1600921104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty