Provider Demographics
NPI:1982277190
Name:COLBY, SHANNON
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:COLBY
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 1:1070 KAMEHAME DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-2859
Mailing Address - Country:US
Mailing Address - Phone:808-284-0520
Mailing Address - Fax:
Practice Address - Street 1:1001 KAMOKILA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2096
Practice Address - Country:US
Practice Address - Phone:808-591-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-24
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-20-125223106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician