MEDICARE: DIANE COLONNELLO,LCSW,PA

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	1041C0700X	Clinical Social Worker	SW1700	FL

General Provider Information

NPI Number	:	1629378898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANE COLONNELLO,LCSW,PA

Provider Business Mailing Address
First Line	:	8192 COLLEGE PKWY
Second Line	:	STE. 50
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5175
Country	:	US
Telephone Number	:	239-275-9665
Fax Number	:

Provider Business Practice Location Address
First Line	:	8192 COLLEGE PKWY
Second Line	:	STE. 50
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5175
Country	:	US
Telephone Number	:	239-275-9665
Fax Number	:	239-267-4438

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. DIANE COLONNELLO
Credential	:	LCSW
Telephone Number	:	239-275-9665

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	10/22/2010

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