Healthcare Provider Details

I. General information

NPI: 1407000524
Provider Name (Legal Business Name): MR. STEPHEN COLLEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14379 ROUTE 9W
RAVENA NY
12143
US

IV. Provider business mailing address

537 ROUTE 9W
GLENMONT NY
12077-3703
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-3124
  • Fax: 518-756-9476
Mailing address:
  • Phone: 518-436-7888
  • Fax: 518-462-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number003906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: