Provider Demographics
NPI:1336405745
Name:COLBERT, SAMANTHA LYNN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
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 1:210 TACOMA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-9370
Mailing Address - Country:US
Mailing Address - Phone:541-479-6329
Mailing Address - Fax:
Practice Address - Street 1:112 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5011
Practice Address - Country:US
Practice Address - Phone:084-655-4332
Practice Address - Fax:208-466-5802
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IDLMSW-40963104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor