Provider Demographics
NPI:1790705887
Name:COLBERT, KIRSTEN LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LEIGH
Last Name:COLBERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:LEIGH
Other - Last Name:JAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1475
Mailing Address - Country:US
Mailing Address - Phone:405-257-6282
Mailing Address - Fax:405-257-2051
Practice Address - Street 1:STATE HIGHWAY 56 & US HIGHWAY 270 JUNCTION
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884
Practice Address - Country:US
Practice Address - Phone:405-257-6282
Practice Address - Fax:405-257-2051
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP78634Medicare UPIN