Basic Information
| Provider Information | |||||||||
| NPI: | 1235198748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDHU | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 726 MARION ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828013546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3077515563 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E HORSETOOTH RD | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805253189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW 511 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 132048300 | 05 | WY | MEDICAID |