Provider Demographics
NPI:1437295565
Name:COLON, VENTURA (CRC)
Entity Type:Individual
Prefix:MR
First Name:VENTURA
Middle Name:
Last Name:COLON
Suffix:
Gender:M
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SOUTH PARK
Mailing Address - Street 2:LACKAWANNA DAASP
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218
Mailing Address - Country:US
Mailing Address - Phone:716-822-2117
Mailing Address - Fax:716-822-8165
Practice Address - Street 1:2600 SOUTH PARK
Practice Address - Street 2:LACKAWANNA DAASP
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218
Practice Address - Country:US
Practice Address - Phone:716-822-2117
Practice Address - Fax:716-822-8165
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7175OtherCASAC
NY00010771OtherCRC