Provider Demographics
NPI:1497272801
Name:ANASTACIO, COLBY
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:ANASTACIO
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 1:381 W BARBOUR ST APT B110
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4916
Mailing Address - Country:US
Mailing Address - Phone:224-381-8184
Mailing Address - Fax:
Practice Address - Street 1:1905 BUSINESS CENTER DR UNIT 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3460
Practice Address - Country:US
Practice Address - Phone:909-435-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst