Provider Demographics
NPI:1295996858
Name:NUSBAUM, COLLEEN (LCSW, CDCI)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:LCSW, CDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 N BINKLEY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7500
Mailing Address - Country:US
Mailing Address - Phone:907-714-4521
Mailing Address - Fax:907-260-4063
Practice Address - Street 1:245 N BINKLEY ST STE 200
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-714-4521
Practice Address - Fax:907-260-4063
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4053101YA0400X
171M00000X
AK12901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG675Medicaid