Provider Demographics
NPI:1851741490
Name:MARA, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MARA
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 1:545 WIGARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3131
Mailing Address - Country:US
Mailing Address - Phone:267-342-3655
Mailing Address - Fax:
Practice Address - Street 1:545 WIGARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3131
Practice Address - Country:US
Practice Address - Phone:267-342-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003096103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst