Provider Demographics
NPI:1417437021
Name:COLBERT, AMBER (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:COLBERT
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 KENSINGTON TRCE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6907
Mailing Address - Country:US
Mailing Address - Phone:678-542-5502
Mailing Address - Fax:
Practice Address - Street 1:212 KENSINGTON TRCE
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6907
Practice Address - Country:US
Practice Address - Phone:678-542-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003227685DMedicaid