Basic Information
| Provider Information | |||||||||
| NPI: | 1114947439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLBERT | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MELINDA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TISEHBERN | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | MELINDA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 9TH STREET | ||||||||
| Address2: | ROOM 205 MAILSTOP 2-3 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958146414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166542431 | ||||||||
| FaxNumber: | 9166543186 | ||||||||
| Practice Location | |||||||||
| Address1: | 11401 SOUTH BLOOMFIELD AVENUE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628637011 | ||||||||
| FaxNumber: | 5628644560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PS418188 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.