Provider Demographics
NPI:1528209590
Name:COLQUITT, IDA VERONICA (LLP)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:VERONICA
Last Name:COLQUITT
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20690 WAYLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5666
Mailing Address - Country:US
Mailing Address - Phone:248-763-0801
Mailing Address - Fax:
Practice Address - Street 1:245 PITKIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3737
Practice Address - Country:US
Practice Address - Phone:313-865-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704425366163W00000X
MI6301013981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163W00000XNursing Service ProvidersRegistered Nurse