Provider Demographics
NPI:1588125546
Name:COLLINS, DEAVON LYNETTE (LPC-IT)
Entity type:Individual
Prefix:
First Name:DEAVON
Middle Name:LYNETTE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 W FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2325
Mailing Address - Country:US
Mailing Address - Phone:414-270-4670
Mailing Address - Fax:
Practice Address - Street 1:4906 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2325
Practice Address - Country:US
Practice Address - Phone:414-270-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4259OtherLPC-IT