Provider Demographics
NPI:1003316399
Name:COLON, CORINA M (BCBA)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:M
Last Name:COLON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S 3052 BLOOMINGDALE RD.
Mailing Address - Street 2:
Mailing Address - City:LA FARGE
Mailing Address - State:WI
Mailing Address - Zip Code:54639
Mailing Address - Country:US
Mailing Address - Phone:262-758-2827
Mailing Address - Fax:
Practice Address - Street 1:901 CALEDONIA ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2616
Practice Address - Country:US
Practice Address - Phone:608-785-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI218-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst