=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770098543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLBY MICHAEL TYSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2017
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5201 VENICE AVE NE STE A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87113-2337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-796-6367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6416 TAUTON RD NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87120-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-918-2901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CTB2024668
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------