Provider Demographics
NPI:1427372812
Name:SUKOLA, KELLY RENAE (MA, IMFT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENAE
Last Name:SUKOLA
Suffix:
Gender:F
Credentials:MA, IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:267 S. MARINE CORPS DRIVE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-646-7972
Mailing Address - Fax:671-647-7972
Practice Address - Street 1:267 S. MARINE CORPS DRIVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-646-7972
Practice Address - Fax:671-647-7972
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUIMF74106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist