Provider Demographics
NPI:1407000524
Name:COLLEEN, STEPHEN
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:COLLEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-3703
Mailing Address - Country:US
Mailing Address - Phone:518-436-7888
Mailing Address - Fax:518-462-9162
Practice Address - Street 1:14379 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143
Practice Address - Country:US
Practice Address - Phone:518-756-3124
Practice Address - Fax:518-756-9476
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003906103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral