Provider Demographics
NPI:1972968444
Name:COLBY, SUSANNAH (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:COLBY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 CAMBRIDGE ST STE 320
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2796
Mailing Address - Country:US
Mailing Address - Phone:617-726-6976
Mailing Address - Fax:617-726-5941
Practice Address - Street 1:175 CAMBRIDGE ST STE 320
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-6976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1202241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10400OtherMEDICARE PTAN Y10400