Provider Demographics
NPI:1861361990
Name:KOLODGE, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KOLODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N SAGEHEN LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5055
Mailing Address - Country:US
Mailing Address - Phone:909-260-5638
Mailing Address - Fax:
Practice Address - Street 1:8620 W EMERALD ST STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4839
Practice Address - Country:US
Practice Address - Phone:208-617-3265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health