Provider Demographics
NPI:1679741490
Name:KLABO, COLLEEN GRAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:GRAY
Last Name:KLABO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1410 W CAMEL BACK LN
Mailing Address - Street 2:#127
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6567
Mailing Address - Country:US
Mailing Address - Phone:206-817-4163
Mailing Address - Fax:
Practice Address - Street 1:2076 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:208-955-7340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IDPSY-202666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1679741490Medicaid
ID200002045Medicare UPIN