Provider Demographics
NPI:1093208506
Name:COLCHA, MIRO (MA, LMHCA)
Entity Type:Individual
Prefix:
First Name:MIRO
Middle Name:
Last Name:COLCHA
Suffix:
Gender:M
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8311 15TH AVE NW APT 401
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-3604
Mailing Address - Country:US
Mailing Address - Phone:407-385-9373
Mailing Address - Fax:
Practice Address - Street 1:2718 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3146
Practice Address - Country:US
Practice Address - Phone:407-385-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2023-10-31
Deactivation Date:2021-06-14
Deactivation Code:
Reactivation Date:2021-06-22
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
106S00000X
WALH61476857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician