Provider Demographics
NPI:1922524784
Name:SPANO, COLLEEN M
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SPANO
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 1:1016 SARAH ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6552
Mailing Address - Country:US
Mailing Address - Phone:574-387-3906
Mailing Address - Fax:
Practice Address - Street 1:1016 SARAH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6552
Practice Address - Country:US
Practice Address - Phone:574-387-3906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health