Provider Demographics
NPI:1902565765
Name:COLBY, MOOREA D
Entity Type:Individual
Prefix:
First Name:MOOREA
Middle Name:D
Last Name:COLBY
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 1:201 50TH AVE APT 21F
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5780
Mailing Address - Country:US
Mailing Address - Phone:978-387-9497
Mailing Address - Fax:
Practice Address - Street 1:201 50TH AVE APT 21F
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5780
Practice Address - Country:US
Practice Address - Phone:978-387-9497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109577104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00000000Medicaid