Provider Demographics
NPI:1487801650
Name:COLAVITO, MARTIN IRVING (CASAC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:IRVING
Last Name:COLAVITO
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17-19 SUSSEX STREET
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2430
Mailing Address - Country:US
Mailing Address - Phone:845-856-6344
Mailing Address - Fax:845-856-4091
Practice Address - Street 1:17-19 SUSSEX STREET
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2430
Practice Address - Country:US
Practice Address - Phone:845-856-6344
Practice Address - Fax:845-856-4091
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)