Provider Demographics
NPI:1073518973
Name:COLONNELLO, DIANE T (MSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:T
Last Name:COLONNELLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8192 COLLEGE PKWY
Mailing Address - Street 2:STE. 50
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-275-9665
Mailing Address - Fax:239-267-4438
Practice Address - Street 1:8192 COLLEGE PKWY
Practice Address - Street 2:STE 50
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5405
Practice Address - Country:US
Practice Address - Phone:239-275-9665
Practice Address - Fax:239-267-4438
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW17001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ4097Medicare ID - Type Unspecified