Healthcare Provider Details

I. General information

NPI: 1447590757
Provider Name (Legal Business Name): COLONIAL CLINIC III, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2013
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N WASHINGTON ST STE 210
SPOKANE WA
99201-2260
US

IV. Provider business mailing address

910 N WASHINGTON ST STE 210
SPOKANE WA
99201-2260
US

V. Phone/Fax

Practice location:
  • Phone: 509-327-9831
  • Fax: 509-327-9857
Mailing address:
  • Phone: 509-327-9831
  • Fax: 509-327-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number32025500
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number32025500
License Number StateWA

VIII. Authorized Official

Name: THOMAS H. STOLZ HUSTON STOLZ
Title or Position: CLINIC DIRECTOR/COUNSELOR
Credential: CDP
Phone: 509-327-9831