Provider Demographics
NPI:1659700524
Name:BOURDEAUX-COLBURN, MONIQUE MARIE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:MARIE
Last Name:BOURDEAUX-COLBURN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WABASHA ST S STE 122
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1822
Mailing Address - Country:US
Mailing Address - Phone:612-326-0775
Mailing Address - Fax:
Practice Address - Street 1:155 WABASHA ST S STE 122
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1822
Practice Address - Country:US
Practice Address - Phone:612-326-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5690103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical