Provider Demographics
NPI:1912273467
Name:COLON, IVAN ALFONSO (PSYD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:ALFONSO
Last Name:COLON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 URB. SERENNA
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727
Mailing Address - Country:US
Mailing Address - Phone:787-354-4508
Mailing Address - Fax:
Practice Address - Street 1:4102 URB. SERENNA
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727
Practice Address - Country:US
Practice Address - Phone:787-354-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4089103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical