Provider Demographics
NPI:1114947439
Name:COLBERT, KELLI MELINDA (PH D)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:MELINDA
Last Name:COLBERT
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:DR
Other - First Name:KELLI
Other - Middle Name:MELINDA
Other - Last Name:TISEHBERN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1600 9TH STREET
Mailing Address - Street 2:ROOM 205 MAILSTOP 2-3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:11401 SOUTH BLOOMFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650
Practice Address - Country:US
Practice Address - Phone:562-863-7011
Practice Address - Fax:562-864-4560
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPS418188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical