Provider Demographics
NPI:1134532856
Name:COLLAZO, MELANIE (LMSW CASAC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:LMSW CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 SEGUINE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3906
Mailing Address - Country:US
Mailing Address - Phone:718-226-2812
Mailing Address - Fax:718-226-2998
Practice Address - Street 1:392 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3906
Practice Address - Country:US
Practice Address - Phone:718-226-2812
Practice Address - Fax:718-226-2998
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8433916104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker