Provider Demographics
NPI:1962052878
Name:COLBERT, CHINITA MONE'E
Entity type:Individual
Prefix:
First Name:CHINITA
Middle Name:MONE'E
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 1:5230 TUCKERMAN LN APT 922
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3862
Mailing Address - Country:US
Mailing Address - Phone:301-213-8347
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3961
Practice Address - Country:US
Practice Address - Phone:301-701-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2023-05-03
Deactivation Date:2023-04-18
Deactivation Code:
Reactivation Date:2023-05-02
Provider Licenses
StateLicense IDTaxonomies
MDLGP13769101YP2500X
DCLGPC200001511101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid