Provider Demographics
NPI:1427476217
Name:COLBERT, BRADFORD (LPC-I)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
Last Name:COLBERT
Suffix:
Gender:M
Credentials:LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 STAGGERBRUSH RD APT 2228
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1052
Mailing Address - Country:US
Mailing Address - Phone:512-569-9695
Mailing Address - Fax:
Practice Address - Street 1:1715 FM 1626 STE 102
Practice Address - Street 2:
Practice Address - City:MANCHACA
Practice Address - State:TX
Practice Address - Zip Code:78652-3549
Practice Address - Country:US
Practice Address - Phone:512-280-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72160101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor