Provider Demographics
NPI:1164705463
Name:COLBURN, MARLENE ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:ELIZABETH
Last Name:COLBURN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 SHELBY SPEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-4528
Mailing Address - Country:US
Mailing Address - Phone:601-794-2402
Mailing Address - Fax:601-794-2404
Practice Address - Street 1:98 SHELBY SPEIGHTS DR
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4528
Practice Address - Country:US
Practice Address - Phone:601-794-2402
Practice Address - Fax:601-794-2404
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06929043Medicaid
MS9005774OtherAETNA
MSP01022232OtherRAILROAD MEDICARE
MS302I655180Medicare PIN