Healthcare Provider Details

I. General information

NPI: 1225945520
Provider Name (Legal Business Name): TEDRA COLLICA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N MAIN ST
MONROE NY
10950-2828
US

IV. Provider business mailing address

444 N MAIN ST
MONROE NY
10950-2828
US

V. Phone/Fax

Practice location:
  • Phone: 917-442-8417
  • Fax:
Mailing address:
  • Phone: 917-442-8417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18-P132995-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: