Provider Demographics
NPI:1053740555
Name:WAY, COLLEEN (LMHC)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WAY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 AVENUE T SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 AVENUE B NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4607
Practice Address - Country:US
Practice Address - Phone:863-412-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 12083101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health