Provider Demographics
NPI:1578640942
Name:COLIS, MICHAEL JOSEPH SR (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:COLIS
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-1311
Mailing Address - Country:US
Mailing Address - Phone:856-310-9696
Mailing Address - Fax:
Practice Address - Street 1:408 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:NJ
Practice Address - Zip Code:08106-1311
Practice Address - Country:US
Practice Address - Phone:856-310-9696
Practice Address - Fax:856-546-7362
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ1599103G00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1599OtherPSYCHOLOGY LICENSE
PA3569OtherPSYCHOLOGY LICENSE
NJ2344602Medicaid
DE448OtherPSYCHOLOGY LICENSE
NJ1599OtherPSYCHOLOGY LICENSE
PA3569OtherPSYCHOLOGY LICENSE