Basic Information
| Provider Information | |||||||||
| NPI: | 1437295565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON | ||||||||
| FirstName: | VENTURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 SOUTH PARK | ||||||||
| Address2: | LACKAWANNA DAASP | ||||||||
| City: | LACKAWANNA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168222117 | ||||||||
| FaxNumber: | 7168228165 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SOUTH PARK | ||||||||
| Address2: | LACKAWANNA DAASP | ||||||||
| City: | LACKAWANNA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168222117 | ||||||||
| FaxNumber: | 7168228165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 7175 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 7175 | 01 | NY | CASAC | OTHER | 00010771 | 01 | NY | CRC | OTHER |