MEDICARE: LAURA COLELLO MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)	99294	VT

General Provider Information

NPI Number	:	1114337037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA COLELLO MS, CGC

Provider Business Mailing Address
First Line	:	44 HILLSIDE CIR
Second Line	:
City	:	ESSEX JCT
State	:	VT
Zip	:	05452-3969
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 COLCHESTER AVE
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05401-1417
Country	:	US
Telephone Number	:	802-847-4495
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2014
Last Update Date	:	04/30/2014

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