Provider Demographics
NPI:1316003940
Name:COLBERT, BRENDA SUSAN (LPC LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:SUSAN
Last Name:COLBERT
Suffix:
Gender:F
Credentials:LPC LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 IRVING PLACE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-424-4623
Mailing Address - Fax:318-424-4678
Practice Address - Street 1:1541 IRVING PLACE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-424-4623
Practice Address - Fax:318-424-4678
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C863Medicare ID - Type Unspecified