Provider Demographics
NPI:1730523481
Name:COLAVITA, SHAUN MARIE
Entity type:Individual
Prefix:MRS
First Name:SHAUN
Middle Name:MARIE
Last Name:COLAVITA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 PROSPECT POINT RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07849
Mailing Address - Country:US
Mailing Address - Phone:862-812-4556
Mailing Address - Fax:
Practice Address - Street 1:319 PROSPECT POINT RD
Practice Address - Street 2:
Practice Address - City:LAKE HOPATCONG
Practice Address - State:NJ
Practice Address - Zip Code:07849-1206
Practice Address - Country:US
Practice Address - Phone:862-812-4556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00248500172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker