Provider Demographics
NPI:1467979724
Name:KOLASA, MICHAEL D (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:KOLASA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72461
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-2461
Mailing Address - Country:US
Mailing Address - Phone:907-347-1989
Mailing Address - Fax:907-459-8201
Practice Address - Street 1:600 UNIVERSITY AVE
Practice Address - Street 2:STE 5
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-347-1989
Practice Address - Fax:907-459-8201
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK122176101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK122176OtherPROFESSIONAL COUNSELOR