Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 0810002516 | VA |
Y | 103TC0700X | Clinical Psychologist | 0810002516 | VA |
NPI | 1003867557 |
---|---|
Provider Name | John Christian Colletti |
First Address | Richmond, VA 23238-4453 |
Second Address | Richmond, VA 23238-4453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 19/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
007712588 | (05) | VA |
291855 | BCBS (01) | VA |
680001531 | PTAN (01) | VA |