Healthcare Provider Details

I. General information

NPI: 1790705887
Provider Name (Legal Business Name): KIRSTEN LEIGH COLBERT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN LEIGH JAKE

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE HIGHWAY 56 & US HIGHWAY 270 JUNCTION
WEWOKA OK
74884
US

IV. Provider business mailing address

PO BOX 1475
WEWOKA OK
74884-1475
US

V. Phone/Fax

Practice location:
  • Phone: 405-257-6282
  • Fax: 405-257-2051
Mailing address:
  • Phone: 405-257-6282
  • Fax: 405-257-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2167
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: