Provider Demographics
NPI:1942365630
Name:KOLES, MITCHELL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:R
Last Name:KOLES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E 200 S
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2022
Mailing Address - Country:US
Mailing Address - Phone:801-350-0121
Mailing Address - Fax:801-350-9582
Practice Address - Street 1:505 E 200 S
Practice Address - Street 2:SUITE 303
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2022
Practice Address - Country:US
Practice Address - Phone:801-350-0121
Practice Address - Fax:801-350-9582
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116938-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS15951Medicare UPIN
UT7554Medicare ID - Type UnspecifiedPSYCHOLOGIST