Provider Demographics
NPI:1447590757
Name:COLONIAL CLINIC III, LLC
Entity Type:Organization
Organization Name:COLONIAL CLINIC III, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS H. STOLZ
Authorized Official - Middle Name:HUSTON
Authorized Official - Last Name:STOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:509-327-9831
Mailing Address - Street 1:910 N WASHINGTON ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2260
Mailing Address - Country:US
Mailing Address - Phone:509-327-9831
Mailing Address - Fax:509-327-9857
Practice Address - Street 1:910 N WASHINGTON ST STE 210
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2260
Practice Address - Country:US
Practice Address - Phone:509-327-9831
Practice Address - Fax:509-327-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA32025500251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251S00000XAgenciesCommunity/Behavioral Health