Provider Demographics
NPI:1497211494
Name:COLLETT, COLLEEN
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:COLLETT
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 1:107 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10998-2621
Mailing Address - Country:US
Mailing Address - Phone:845-649-6466
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1636
Practice Address - Country:US
Practice Address - Phone:845-458-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130313383171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator