Healthcare Provider Details

I. General information

NPI: 1194640821
Provider Name (Legal Business Name): MARISSA COLONNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 9TH ST W
BRADENTON FL
34205-7700
US

IV. Provider business mailing address

3301 32ND AVE S UNIT 367
ST PETERSBURG FL
33712-3756
US

V. Phone/Fax

Practice location:
  • Phone: 315-771-0102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: