Basic Information
| Provider Information | |||||||||
| NPI: | 1295996858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUSBAUM | ||||||||
| FirstName: | COLLEEN | ||||||||
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| Credential: | LCSW, CDCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 N BINKLEY ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144521 | ||||||||
| FaxNumber: | 9072604063 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 N BINKLEY ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144521 | ||||||||
| FaxNumber: | 9072604063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 4053 | AK | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 1290 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | CMG675 | 05 | AK | MEDICAID |