Provider Demographics
NPI:1184973174
Name:COLBERT, DEIDRE DIANNA (LMP)
Entity type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:DIANNA
Last Name:COLBERT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 NE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9207
Mailing Address - Country:US
Mailing Address - Phone:360-471-4177
Mailing Address - Fax:
Practice Address - Street 1:10868 NW MYHRE PL
Practice Address - Street 2:SUITE 102
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7618
Practice Address - Country:US
Practice Address - Phone:360-471-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60066734225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist