Provider Demographics
NPI:1770892721
Name:KOURAKOS, COLLEEN RENEE (MACCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:RENEE
Last Name:KOURAKOS
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22 222 SEVEN BRIDGES ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAPPAQUA
Mailing Address - State:NY
Mailing Address - Zip Code:10514-0022
Mailing Address - Country:US
Mailing Address - Phone:914-666-7330
Mailing Address - Fax:
Practice Address - Street 1:222 SEVEN BRIDGES ROAD
Practice Address - Street 2:
Practice Address - City:CHAPPAQUA
Practice Address - State:NY
Practice Address - Zip Code:10514-0022
Practice Address - Country:US
Practice Address - Phone:914-666-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006084-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist