Provider Demographics
NPI:1760975064
Name:KOLODZIEJCZYK, MICHELLE ANN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:KOLODZIEJCZYK
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 1:4803 FERN LK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-2076
Mailing Address - Country:US
Mailing Address - Phone:830-719-9582
Mailing Address - Fax:
Practice Address - Street 1:4803 FERN LK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-2076
Practice Address - Country:US
Practice Address - Phone:830-719-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-56795106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician