Provider Demographics
NPI:1114663937
Name:COLBERT, TASHA NICOLE
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:NICOLE
Last Name:COLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 SW 11TH ST APT 219
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-4305
Mailing Address - Country:US
Mailing Address - Phone:503-516-1469
Mailing Address - Fax:
Practice Address - Street 1:1817 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3960
Practice Address - Country:US
Practice Address - Phone:503-719-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2023-04-25
Deactivation Date:2022-09-07
Deactivation Code:
Reactivation Date:2023-04-25
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)