Provider Demographics
NPI:1437487436
Name:COLBERT, MOSES L
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:L
Last Name:COLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 DR MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-2338
Mailing Address - Country:US
Mailing Address - Phone:980-251-7227
Mailing Address - Fax:704-861-1912
Practice Address - Street 1:602 N MARIETTA ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-2338
Practice Address - Country:US
Practice Address - Phone:980-251-7227
Practice Address - Fax:704-861-1912
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YM0800X
NC3107231251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3107231OtherSTATE ID FOR WE ARE A NON PROFIT ORGANIZATION