Healthcare Provider Details

I. General information

NPI: 1528493319
Provider Name (Legal Business Name): COLBY WUILLERMIN L.A.C., N.C.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S 3RD AVE
HIGHLAND PARK NJ
08904-2510
US

IV. Provider business mailing address

307 19TH ST S
BRIGANTINE NJ
08203-2025
US

V. Phone/Fax

Practice location:
  • Phone: 732-246-8439
  • Fax:
Mailing address:
  • Phone: 609-457-6489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health
License Number37AC00170800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: