Provider Demographics
NPI:1013751155
Name:COLT, LUNA AURELIA (LCPC-C)
Entity type:Individual
Prefix:
First Name:LUNA
Middle Name:AURELIA
Last Name:COLT
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5403
Mailing Address - Country:US
Mailing Address - Phone:802-595-3759
Mailing Address - Fax:
Practice Address - Street 1:6 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2161
Practice Address - Country:US
Practice Address - Phone:802-595-3759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL7463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health