Provider Demographics
NPI:1265787964
Name:TANAKA, COLLEEN MARY (MS ED)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:TANAKA
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARY
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS ED
Mailing Address - Street 1:38 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1723
Mailing Address - Country:US
Mailing Address - Phone:516-946-3136
Mailing Address - Fax:
Practice Address - Street 1:90 HENRY ST
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2335
Practice Address - Country:US
Practice Address - Phone:516-239-2182
Practice Address - Fax:516-374-1068
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1074492171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY171M000000XMedicaid