Provider Demographics
NPI:1134298854
Name:KOLTONUK, JANICE LYN (LISW)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:LYN
Last Name:KOLTONUK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:JAN
Other - Middle Name:LYN
Other - Last Name:KOLTONUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:4316 CARLISLE BLVD NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4829
Mailing Address - Country:US
Mailing Address - Phone:505-837-2100
Mailing Address - Fax:505-888-7943
Practice Address - Street 1:4316 CARLISLE BLVD NE
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4829
Practice Address - Country:US
Practice Address - Phone:505-837-2100
Practice Address - Fax:505-888-7943
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI38821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical