Healthcare Provider Details

I. General information

NPI: 1710754239
Provider Name (Legal Business Name): COLBY MARIE ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11945 CONQUEST ST
BIRCH RUN MI
48415
US

IV. Provider business mailing address

4635 RATHBUN RD
BIRCH RUN MI
48415
US

V. Phone/Fax

Practice location:
  • Phone: 989-624-9293
  • Fax:
Mailing address:
  • Phone: 269-506-8748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501014546
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: