Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | F18736 | NJ |
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 37LC00011300 | NJ |
N | 104100000X | Social Worker | 44SW00619000 | NJ |
NPI | 1003992512 |
---|---|
Provider Name | Keith Colbert |
First Address | Irvington, NJ 07111-1861 |
Second Address | Irvington, NJ 07111-1861 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A163636 | (02) | NJ |