Basic Information
| Provider Information | |||||||||
| NPI: | 1821628843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLBERT | ||||||||
| FirstName: | KINDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 153 N U ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594459094 | ||||||||
| FaxNumber: | 5594459083 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 N U ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594459094 | ||||||||
| FaxNumber: | 5594459083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2020 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | B6197909 | 01 | CA | DL | OTHER |