Provider Demographics
NPI:1447666532
Name:REZAYAT, COLBY JAMES (LICSW, SUDPT, GMHS)
Entity type:Individual
Prefix:MR
First Name:COLBY
Middle Name:JAMES
Last Name:REZAYAT
Suffix:
Gender:M
Credentials:LICSW, SUDPT, GMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-3417
Mailing Address - Country:US
Mailing Address - Phone:360-421-2065
Mailing Address - Fax:360-757-0136
Practice Address - Street 1:816 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3417
Practice Address - Country:US
Practice Address - Phone:360-421-2065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW610963391041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical