Provider Demographics
NPI:1497749303
Name:KOLMETZ, MARCUS P (MA CCCA)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:P
Last Name:KOLMETZ
Suffix:
Gender:M
Credentials:MA CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 S HIGHWAY 77 STE A
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-4730
Mailing Address - Country:US
Mailing Address - Phone:850-769-2705
Mailing Address - Fax:850-769-1097
Practice Address - Street 1:2518 S HIGHWAY 77 STE A
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4730
Practice Address - Country:US
Practice Address - Phone:850-769-2705
Practice Address - Fax:850-769-1097
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1111231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600330300Medicaid
FLK0176Medicare ID - Type Unspecified
FL600330300Medicaid