Basic Information
| Provider Information | |||||||||
| NPI: | 1316475445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLATO | ||||||||
| FirstName: | MARILYNN | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 175 MIDDLE ST UNIT 1201 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327463625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079554001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1260 UPPER HEMBREE RD STE D | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703870593 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-16-18732 | FL | N | 103K00000X | 1-19-37295 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 003225511A | 05 | GA | MEDICAID | 020813000 | 05 | FL | MEDICAID |