Provider Demographics
NPI:1821187543
Name:KOLLES, MARY THERESE (MA, PRP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESE
Last Name:KOLLES
Suffix:
Gender:F
Credentials:MA, PRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 GLEN PAUL CT
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8114
Mailing Address - Country:US
Mailing Address - Phone:612-435-7210
Mailing Address - Fax:612-435-7201
Practice Address - Street 1:1313 5TH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4504
Practice Address - Country:US
Practice Address - Phone:612-435-7210
Practice Address - Fax:612-435-7201
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171613101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health