Provider Demographics
NPI:1700568243
Name:COLBURN, MANDY (LADAC II)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:COLBURN
Suffix:
Gender:F
Credentials:LADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 KELSAY DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-3004
Mailing Address - Country:US
Mailing Address - Phone:865-206-6971
Mailing Address - Fax:
Practice Address - Street 1:302 KELSAY DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-3004
Practice Address - Country:US
Practice Address - Phone:865-206-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)