Basic Information
| Provider Information | |||||||||
| NPI: | 1568579126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLBURN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 FOREST ST | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786266718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129340021 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 ALLENTOWN PKWY STE 206 | ||||||||
| Address2: | |||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750024215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331010 | ||||||||
| FaxNumber: | 2146236692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 005066 | CT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 29704 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 192371601 | 05 | TX | MEDICAID | 612951 | 01 | TX | MEDICARE PROVIDER NUMBER | OTHER |