Provider Demographics
NPI:1114496072
Name:COLBURN, KIRSTEN ANN (103K00000X)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANN
Last Name:COLBURN
Suffix:
Gender:F
Credentials:103K00000X
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:ANN
Other - Last Name:COLBURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:78 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4594
Mailing Address - Country:US
Mailing Address - Phone:802-775-8224
Mailing Address - Fax:
Practice Address - Street 1:6 SOUTHSIDE RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1409
Practice Address - Country:US
Practice Address - Phone:978-762-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1460134180103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst