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General NPI Number Information
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NPI Number | 1770536054
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Entity Type | Organization
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Legal Business Name | COLONY BEHAVIORAL HEALTH GROUP, PLLC
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Dates
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Enumeration Date | 05/18/2006
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Last Update Date | 06/25/2009
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Provider Practice Location Address
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Address Line | 2804 VILLAGE WAY
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City | TRENT WOODS
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State | NC
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Zip | 28562-7305
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Country | US
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Telephone | 252-636-0112
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Fax | 252-634-9778
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Provider Business Mailing Address
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Address Line | 2804 VILLAGE WAY
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City | TRENT WOODS
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State | NC
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Zip | 28562-7305
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Country | US
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Telephone | 252-636-0112
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Fax | 252-634-9778
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. BETHANNE THUMM JACOBSON
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Credential | PH.D.
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Telephone | 252-636-0112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2021
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LPC1030
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | PCAS28
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 3037
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License Number State | NC
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