Provider Demographics
NPI:1689919060
Name:COLLAZO, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:COLLAZO
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 1:20 LAKEPOINTE CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-8113
Mailing Address - Country:US
Mailing Address - Phone:407-744-8599
Mailing Address - Fax:407-988-1600
Practice Address - Street 1:6925 LAKE ELLENOR DR STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4648
Practice Address - Country:US
Practice Address - Phone:407-552-5444
Practice Address - Fax:407-988-1600
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health