Provider Demographics
NPI:1538270913
Name:SIAKWAN, COLLINS YEBOA (MSW, LCAS)
Entity type:Individual
Prefix:MR
First Name:COLLINS
Middle Name:YEBOA
Last Name:SIAKWAN
Suffix:
Gender:M
Credentials:MSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 BALLARDS CROSSROADS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4707
Mailing Address - Country:US
Mailing Address - Phone:252-561-8417
Mailing Address - Fax:252-752-4949
Practice Address - Street 1:2245 STANTONSBURG RD
Practice Address - Street 2:SUITE O
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2868
Practice Address - Country:US
Practice Address - Phone:252-752-0130
Practice Address - Fax:252-752-4949
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC143K0OtherBCBS
NC6111899Medicaid