Provider Demographics
NPI:1316767791
Name:DEFOREST COLVIG, LILY KATHRYN (LISW)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:KATHRYN
Last Name:DEFOREST COLVIG
Suffix:
Gender:U
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LINCOLN WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-7595
Mailing Address - Country:US
Mailing Address - Phone:515-239-4410
Mailing Address - Fax:515-663-4885
Practice Address - Street 1:3600 LINCOLN WAY STE 4
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7595
Practice Address - Country:US
Practice Address - Phone:515-239-4410
Practice Address - Fax:515-663-4885
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1130011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical