Healthcare Provider Details

I. General information

NPI: 1356646038
Provider Name (Legal Business Name): GWEN MARIE COLORITO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 STAR BATT DR SUITE 200
ROCHESTER HILLS MI
48309-3712
US

IV. Provider business mailing address

1901 STAR BATT DR SUITE 200
ROCHESTER HILLS MI
48309-3712
US

V. Phone/Fax

Practice location:
  • Phone: 248-844-5690
  • Fax: 248-844-5691
Mailing address:
  • Phone: 248-844-5690
  • Fax: 248-844-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801064651
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: