Provider Demographics
NPI:1194886283
Name:COLON, MILDRED IVETTE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:IVETTE
Last Name:COLON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LIGHTHOUSE WOMENS RESIDENCE
Mailing Address - Street 2:244 HEMPSTEAD AVENUE
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:716-831-7877
Mailing Address - Fax:716-831-8666
Practice Address - Street 1:LIGHTHOUSE WOMENS RESIDENCE
Practice Address - Street 2:244 HEMPSTEAD AVENUE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-831-7877
Practice Address - Fax:716-831-8666
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073564-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY073564-1OtherLCSW