Provider Demographics
NPI:1043510357
Name:PTAK, COLLEEN M (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:PTAK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:DOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-S
Mailing Address - Street 1:3146 SCRANTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3146 SCRANTON RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1652
Practice Address - Country:US
Practice Address - Phone:216-671-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI07000581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical