Provider Demographics
NPI:1003867557
Name:COLLETTI, JOHN CHRISTIAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTIAN
Last Name:COLLETTI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9515 CATESBY LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4453
Mailing Address - Country:US
Mailing Address - Phone:804-741-7500
Mailing Address - Fax:804-741-7900
Practice Address - Street 1:9515 CATESBY LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-4453
Practice Address - Country:US
Practice Address - Phone:804-741-7500
Practice Address - Fax:804-741-7900
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007712588Medicaid
VA291855OtherBCBS
VA680001531OtherPTAN