Provider Demographics
NPI:1104265164
Name:COLEBURN, LILA AGNES (PHD)
Entity type:Individual
Prefix:DR
First Name:LILA
Middle Name:AGNES
Last Name:COLEBURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 RIVERSIDE DR
Mailing Address - Street 2:#3C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1859
Mailing Address - Country:US
Mailing Address - Phone:212-580-2547
Mailing Address - Fax:212-531-1431
Practice Address - Street 1:98 RIVERSIDE DR
Practice Address - Street 2:#1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5323
Practice Address - Country:US
Practice Address - Phone:212-580-2547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-22
Last Update Date:2013-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08542103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical