Healthcare Provider Details

I. General information

NPI: 1770098543
Provider Name (Legal Business Name): COLBY MICHAEL TYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2017
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 VENICE AVE NE STE A
ALBUQUERQUE NM
87113-2337
US

IV. Provider business mailing address

6416 TAUTON RD NW
ALBUQUERQUE NM
87120-2040
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-6367
  • Fax:
Mailing address:
  • Phone: 505-918-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB2024668
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: