Provider Demographics
NPI:1336780329
Name:BLOXOM, COLTER (LPC)
Entity type:Individual
Prefix:MR
First Name:COLTER
Middle Name:
Last Name:BLOXOM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 E SHEA BLVD STE 188
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3354
Mailing Address - Country:US
Mailing Address - Phone:602-529-6557
Mailing Address - Fax:480-485-7938
Practice Address - Street 1:3420 E SHEA BLVD STE 188
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3354
Practice Address - Country:US
Practice Address - Phone:602-529-6557
Practice Address - Fax:480-485-7938
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health