Provider Demographics
NPI:1679170526
Name:COLON, MIRCHELISE
Entity Type:Individual
Prefix:
First Name:MIRCHELISE
Middle Name:
Last Name:COLON
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 1133
Mailing Address - Street 2:
Mailing Address - City:MOROVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00687-1133
Mailing Address - Country:US
Mailing Address - Phone:939-247-8141
Mailing Address - Fax:
Practice Address - Street 1:URB LAS COLLINAS S1
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:939-247-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4423-1235Z00000X
PR4260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty