Provider Demographics
NPI:1568579126
Name:COLBURN, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:COLBURN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6718
Mailing Address - Country:US
Mailing Address - Phone:512-934-0021
Mailing Address - Fax:
Practice Address - Street 1:100 ALLENTOWN PKWY STE 206
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-4215
Practice Address - Country:US
Practice Address - Phone:972-233-1010
Practice Address - Fax:214-623-6692
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0050661041C0700X
TX297041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192371601Medicaid
TX612951OtherMEDICARE PROVIDER NUMBER