Provider Demographics
NPI:1639637556
Name:COLANTINO, LAURA ALYCE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ALYCE
Last Name:COLANTINO
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 1:307 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOAMI
Mailing Address - State:IL
Mailing Address - Zip Code:62661-3322
Mailing Address - Country:US
Mailing Address - Phone:217-415-1721
Mailing Address - Fax:
Practice Address - Street 1:3000 LENHART RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9203
Practice Address - Country:US
Practice Address - Phone:217-698-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional