Basic Information
| Provider Information | |||||||||
| NPI: | 1144829466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON LABOY | ||||||||
| FirstName: | MARIANETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 E TAMPA ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658061131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178511551 | ||||||||
| FaxNumber: | 4178653479 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 E TAMPA ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658061131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178511551 | ||||||||
| FaxNumber: | 4178653479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2020035053 | MO | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.