Provider Demographics
NPI:1770536054
Name:COLONY BEHAVIORAL HEALTH GROUP, PLLC
Entity type:Organization
Organization Name:COLONY BEHAVIORAL HEALTH GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BETHANNE
Authorized Official - Middle Name:THUMM
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-636-0112
Mailing Address - Street 1:2804 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7305
Mailing Address - Country:US
Mailing Address - Phone:252-636-0112
Mailing Address - Fax:252-634-9778
Practice Address - Street 1:2804 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:TRENT WOODS
Practice Address - State:NC
Practice Address - Zip Code:28562-7305
Practice Address - Country:US
Practice Address - Phone:252-636-0112
Practice Address - Fax:252-634-9778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021103TC0700X
NCLPC1030101Y00000X
NCPCAS28101YA0400X
NC3037103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006464Medicaid
NC0197QOtherBLUE CROSS BLUE SHEILD
NC6006464Medicaid