=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043569379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARTOLOME E COLOM LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 10/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 452 OSCEOLA ST SUITE 101
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-7817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-782-5525
-----------------------------------------------------
Fax | 386-943-9976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1292 BRAMLEY LN
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-0850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-782-5525
-----------------------------------------------------
Fax | 386-943-9976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH11368
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------