Provider Demographics
NPI:1619408549
Name:COLPETZER, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:COLPETZER
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:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48615-0334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4511 S MAGRUDDER RD
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MI
Practice Address - Zip Code:48615-9633
Practice Address - Country:US
Practice Address - Phone:989-284-7318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician