Provider Demographics
NPI:1700110830
Name:COLOMB, HEATHER STATON (LCSW, LCAS-P)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:STATON
Last Name:COLOMB
Suffix:
Gender:F
Credentials:LCSW, LCAS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-7760
Mailing Address - Fax:704-316-7761
Practice Address - Street 1:2300 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1562
Practice Address - Country:US
Practice Address - Phone:704-316-7760
Practice Address - Fax:704-316-7761
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP005145101Y00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor