Provider Demographics
NPI:1962493007
Name:COLONIAL CLINIC II, LLC
Entity type:Organization
Organization Name:COLONIAL CLINIC II, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLYAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CDP,NCACII,SAP
Authorized Official - Phone:509-327-9831
Mailing Address - Street 1:910 N WASHINGTON ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2202
Mailing Address - Country:US
Mailing Address - Phone:509-327-9831
Mailing Address - Fax:509-327-9857
Practice Address - Street 1:910 N WASHINGTON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2202
Practice Address - Country:US
Practice Address - Phone:509-327-9831
Practice Address - Fax:509-327-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32025500OtherCHEMICAL DEPENDENCY TREAT
WAJ0HY6W00OtherONE HLTH. PORT ID.
WA32025500OtherCHEMICAL DEPENDENCY TREAT
WAJ0HY6W00OtherONE HLTH. PORT ID.