Healthcare Provider Details

I. General information

NPI: 1043812019
Provider Name (Legal Business Name): STEPHANIE COLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 04/23/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CHERRY LN STE 101
MANTECA CA
95337
US

IV. Provider business mailing address

PO BOX 5157 301 CHERRY LN. STE 101
MANTECA CA
95337
US

V. Phone/Fax

Practice location:
  • Phone: 209-647-6200
  • Fax:
Mailing address:
  • Phone: 209-647-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: