Provider Demographics
NPI:1518231893
Name:SOUTH WHIDBEY PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTH WHIDBEY PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:FAULDER COLBY, PH.D.; SWPS, PLLC; SWPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAULDER
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-341-4484
Mailing Address - Street 1:PO BOX 439
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-0439
Mailing Address - Country:US
Mailing Address - Phone:360-341-4484
Mailing Address - Fax:866-627-8142
Practice Address - Street 1:11042 SR 525
Practice Address - Street 2:SUITE 206
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-8600
Practice Address - Country:US
Practice Address - Phone:360-341-4484
Practice Address - Fax:866-627-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-03
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 00001909103G00000X, 103T00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADT0357OtherRAILROAD MEDICARE PIN
WA2017481Medicaid
WADT0357OtherRAILROAD MEDICARE PIN