Provider Demographics
NPI:1598063943
Name:KOLRUD, KOREY JOHN (BA)
Entity Type:Individual
Prefix:
First Name:KOREY
Middle Name:JOHN
Last Name:KOLRUD
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2840
Mailing Address - Country:US
Mailing Address - Phone:425-343-2662
Mailing Address - Fax:425-349-7256
Practice Address - Street 1:221 AVENUE B
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2840
Practice Address - Country:US
Practice Address - Phone:425-343-2662
Practice Address - Fax:425-349-7256
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60205587171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator