Provider Demographics
NPI:1760522262
Name:COLON, LISA DOREEN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DOREEN
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 1:1220 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:386-416-1023
Mailing Address - Fax:386-416-1037
Practice Address - Street 1:311 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6733
Practice Address - Country:US
Practice Address - Phone:386-416-1040
Practice Address - Fax:386-416-1037
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health