Provider Demographics
NPI:1699490284
Name:COLVIN, WALLACE SPRUGEON IV (MA)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:SPRUGEON
Last Name:COLVIN
Suffix:IV
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 33RD ST APT 810
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2755 N PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6109
Practice Address - Country:US
Practice Address - Phone:312-259-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional