Provider Demographics
NPI:1679015994
Name:COLBERT, IVY GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:GRACE
Last Name:COLBERT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:GRACE
Other - Last Name:ORLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:457 N ELM STREET
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3001
Mailing Address - Country:US
Mailing Address - Phone:760-489-1969
Mailing Address - Fax:760-489-5226
Practice Address - Street 1:457 N ELM STREET
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3001
Practice Address - Country:US
Practice Address - Phone:760-489-1969
Practice Address - Fax:760-489-5226
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT292158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14854Medicare UPIN