Basic Information
| Provider Information | |||||||||
| NPI: | 1114496072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLBURN | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | 103K00000X | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLBURN | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 78 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027758224 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 SOUTHSIDE RD | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019231409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787628352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2018 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1460134180 | VT | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.