Provider Demographics
NPI:1922764893
Name:COLON, WILMARIS
Entity Type:Individual
Prefix:
First Name:WILMARIS
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 1:1709 MABBETTE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5321
Mailing Address - Country:US
Mailing Address - Phone:407-925-4150
Mailing Address - Fax:
Practice Address - Street 1:4862 ROCKVALE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3368
Practice Address - Country:US
Practice Address - Phone:407-308-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-21-190803Medicaid