Healthcare Provider Details

I. General information

NPI: 1396017596
Provider Name (Legal Business Name): BILLY COLBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 S ATLANTIC ST
SEATTLE WA
98144-3615
US

IV. Provider business mailing address

3421 35TH AVE S
SEATTLE WA
98144-7101
US

V. Phone/Fax

Practice location:
  • Phone: 206-329-2050
  • Fax: 206-726-8564
Mailing address:
  • Phone: 206-329-2050
  • Fax: 206-726-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCG60154026
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: