Provider Demographics
NPI:1710759865
Name:COLBERT, CHANCE
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:
Last Name:COLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4195 US HIGHWAY 1 STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5385
Mailing Address - Country:US
Mailing Address - Phone:815-922-1834
Mailing Address - Fax:
Practice Address - Street 1:4194 US 1 STE 101
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-877-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician