Individual
ETHAN COLBURN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CMHCI
Contact information
Practice address
21360 N 1450 E, MORONI, UT 84646-0461
(435) 445-5200
(435) 445-5201
Mailing address
PO BOX 461, 21360 N 1450 E, MORONI, UT 84646-0461
(435) 445-5200
(435) 445-5201
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
272503815
—
UT
Enumeration date
08/28/2015
Last updated
08/28/2015
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