Provider Demographics
NPI:1356646038
Name:COLORITO, GWEN MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
Last Name:COLORITO
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 1:1901 STAR BATT DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3712
Mailing Address - Country:US
Mailing Address - Phone:248-844-5690
Mailing Address - Fax:248-844-5691
Practice Address - Street 1:1901 STAR BATT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3712
Practice Address - Country:US
Practice Address - Phone:248-844-5690
Practice Address - Fax:248-844-5691
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010646511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0899941OtherBCBSM
MI6801064651OtherSTATE LICENSE
MIMI1188007Medicare PIN
MIP17390007Medicare PIN