Provider Demographics
NPI:1134445661
Name:COLSON, MYCHAEL BETH
Entity type:Individual
Prefix:MRS
First Name:MYCHAEL
Middle Name:BETH
Last Name:COLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 MCGUIRE AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4036
Mailing Address - Country:US
Mailing Address - Phone:270-442-6168
Mailing Address - Fax:
Practice Address - Street 1:867 MCGUIRE AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4036
Practice Address - Country:US
Practice Address - Phone:270-442-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-09-078235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist