Provider Demographics
NPI:1619578390
Name:COLOSIMO, TODD JAMES SR (CADC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:JAMES
Last Name:COLOSIMO
Suffix:SR
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 SULTANA DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-8511
Mailing Address - Country:US
Mailing Address - Phone:910-212-0715
Mailing Address - Fax:
Practice Address - Street 1:104 GEORGE BISHOP PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7335
Practice Address - Country:US
Practice Address - Phone:843-903-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-26817101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)