Provider Demographics
NPI:1770098543
Name:TYSON, COLBY MICHAEL
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:MICHAEL
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 TAUTON RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2040
Mailing Address - Country:US
Mailing Address - Phone:505-918-2901
Mailing Address - Fax:
Practice Address - Street 1:5201 VENICE AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2337
Practice Address - Country:US
Practice Address - Phone:505-796-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-02
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB2024668101YM0800X
373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist