Provider Demographics
NPI:1235475807
Name:COLON, MARIELY
Entity Type:Individual
Prefix:
First Name:MARIELY
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 1:2528 WAGON WHEEL TRAIL
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772
Mailing Address - Country:US
Mailing Address - Phone:407-541-7965
Mailing Address - Fax:407-307-2328
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7589
Practice Address - Country:US
Practice Address - Phone:407-541-7965
Practice Address - Fax:407-307-2328
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-29
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018409700Medicaid