Provider Demographics
NPI:1043812019
Name:COLON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5157
Mailing Address - Street 2:301 CHERRY LN. STE 101
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337
Mailing Address - Country:US
Mailing Address - Phone:209-647-6200
Mailing Address - Fax:
Practice Address - Street 1:301 CHERRY LN STE 101
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337
Practice Address - Country:US
Practice Address - Phone:209-647-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician