Provider Demographics
NPI:1407140940
Name:COLBY, MICHAEL J (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:COLBY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-969-9945
Mailing Address - Fax:201-944-0488
Practice Address - Street 1:7 S ALLIANCE DR STE 211B
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-7297
Practice Address - Country:US
Practice Address - Phone:843-553-4383
Practice Address - Fax:843-553-4384
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9660225100000X
WA225100000X
ID5295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3929Medicaid