Provider Demographics
NPI:1396843579
Name:BROGDON, COLVIN JEFFREY (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:COLVIN
Middle Name:JEFFREY
Last Name:BROGDON
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13821 CROSS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:UPATOI
Mailing Address - State:GA
Mailing Address - Zip Code:31829-1802
Mailing Address - Country:US
Mailing Address - Phone:706-569-9212
Mailing Address - Fax:706-569-9212
Practice Address - Street 1:113 BASCOM CT STE C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2798
Practice Address - Country:US
Practice Address - Phone:706-569-7254
Practice Address - Fax:706-569-9212
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002957101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA576838803AMedicaid