Provider Demographics
NPI:1255902151
Name:COLLAZO, MAGDA GISELLE (CT)
Entity type:Individual
Prefix:
First Name:MAGDA
Middle Name:GISELLE
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 VANDALIA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3945
Mailing Address - Country:US
Mailing Address - Phone:216-507-8045
Mailing Address - Fax:
Practice Address - Street 1:5209 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2224
Practice Address - Country:US
Practice Address - Phone:216-815-1019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OHC.2204434101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor