Provider Demographics
NPI:1710213418
Name:KOLB, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KOLB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ANASAZI DR
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-8524
Mailing Address - Country:US
Mailing Address - Phone:575-202-6030
Mailing Address - Fax:
Practice Address - Street 1:12165 STATE HIGHWAY 14 N STE B7
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9538
Practice Address - Country:US
Practice Address - Phone:505-913-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15171035Medicaid