Provider Demographics
NPI:1417508052
Name:COLBURN, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:COLBURN
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:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577-0917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 W PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4412
Practice Address - Country:US
Practice Address - Phone:360-515-7342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator