Provider Demographics
NPI:1912314832
Name:COLLAZO, LEONOR E
Entity Type:Individual
Prefix:MRS
First Name:LEONOR
Middle Name:E
Last Name:COLLAZO
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:P.O. BOX 51319
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33994-1116
Mailing Address - Country:US
Mailing Address - Phone:239-334-6160
Mailing Address - Fax:239-334-1339
Practice Address - Street 1:1650 MEDICAL LANE STE 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1119
Practice Address - Country:US
Practice Address - Phone:239-334-6160
Practice Address - Fax:239-334-1339
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X, 222Q00000X
104100000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
222Q00000XOtherEARLY INTERVENTION
FL023180200Medicaid
FL222Q00000XOtherEI
FL222Q00000XMedicaid