Provider Demographics
NPI:1629441357
Name:COLOMBATTO, MICHAEL (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COLOMBATTO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S DEARBORN ST APT 1211
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1895
Mailing Address - Country:US
Mailing Address - Phone:312-859-6512
Mailing Address - Fax:
Practice Address - Street 1:600 S DEARBORN ST APT 1211
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1895
Practice Address - Country:US
Practice Address - Phone:312-859-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005566103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical