Provider Demographics
NPI:1740548643
Name:BROTHERTON, COLBY P (LCO)
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:P
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:LCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19221 INTERSTATE 45 S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-8756
Mailing Address - Country:US
Mailing Address - Phone:281-419-6638
Mailing Address - Fax:281-419-3757
Practice Address - Street 1:19221 INTERSTATE 45 S
Practice Address - Street 2:SUITE 110
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-8756
Practice Address - Country:US
Practice Address - Phone:281-419-6638
Practice Address - Fax:281-419-3757
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX181222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist