Provider Demographics
NPI:1134766470
Name:DAVERN, COLLEEN CRYSTAL (LADC LPCC)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:CRYSTAL
Last Name:DAVERN
Suffix:
Gender:F
Credentials:LADC LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8852 ARKOLA RD
Mailing Address - Street 2:
Mailing Address - City:KELSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55724-8502
Mailing Address - Country:US
Mailing Address - Phone:218-348-2998
Mailing Address - Fax:
Practice Address - Street 1:2835 W SAINT GERMAIN ST STE 550
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6389
Practice Address - Country:US
Practice Address - Phone:320-251-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303967101YA0400X
MN1869101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health