Provider Demographics
NPI:1639776693
Name:COLBERT, TAEKO MICHELLE
Entity type:Individual
Prefix:
First Name:TAEKO
Middle Name:MICHELLE
Last Name:COLBERT
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 1:11331 S LILY MAY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-6001
Mailing Address - Country:US
Mailing Address - Phone:307-371-5429
Mailing Address - Fax:
Practice Address - Street 1:1537 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5315
Practice Address - Country:US
Practice Address - Phone:385-777-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12872334-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health