Provider Demographics
NPI:1457654428
Name:DR. MARY H. KOLPACOFF, INC., P.S.
Entity Type:Organization
Organization Name:DR. MARY H. KOLPACOFF, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLPACOFF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:425-451-9492
Mailing Address - Street 1:1400 112TH AVE SE
Mailing Address - Street 2:#221
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6901
Mailing Address - Country:US
Mailing Address - Phone:425-451-9492
Mailing Address - Fax:
Practice Address - Street 1:1400 112TH AVE SE
Practice Address - Street 2:#221
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6901
Practice Address - Country:US
Practice Address - Phone:425-451-9492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144343591OtherNPI