Provider Demographics
NPI:1629835145
Name:COLONEL, JOSEPH WYATT (AMFT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WYATT
Last Name:COLONEL
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NUT TREE RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3508
Mailing Address - Country:US
Mailing Address - Phone:859-630-7391
Mailing Address - Fax:
Practice Address - Street 1:101 MARKHAM AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2312
Practice Address - Country:US
Practice Address - Phone:707-453-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
145247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist