Provider Demographics
NPI:1932546462
Name:COLBERT, TAMEKO L
Entity Type:Individual
Prefix:
First Name:TAMEKO
Middle Name:L
Last Name:COLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 N PENNSYLVANIA AVE APT 1934
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-5914
Mailing Address - Country:US
Mailing Address - Phone:405-371-0479
Mailing Address - Fax:405-810-5207
Practice Address - Street 1:2617 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-371-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1932546462Medicaid