Provider Demographics
NPI:1710323365
Name:KOLB, COLLEEN (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:KOLB
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:DE FOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-1123
Mailing Address - Country:US
Mailing Address - Phone:608-495-0869
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:1716 FORDEM AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4604
Practice Address - Country:US
Practice Address - Phone:608-221-3511
Practice Address - Fax:608-221-3514
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1023-124106H00000X
WI308228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710323365Medicaid