Basic Information
| Provider Information | |||||||||
| NPI: | 1376060038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REEVES | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | DEPT. 781625 | ||||||||
| Address2: | PO BOX 78000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 BUTTERFLY GARDENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558695 | ||||||||
| FaxNumber: | 6143557855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2017 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | S1610506TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | S.1802324 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I.2002342 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |