Provider Demographics
NPI:1023591153
Name:KOLACSKY, MARY K
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:KOLACSKY
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 1:1873 BONKIRK DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9587
Mailing Address - Country:US
Mailing Address - Phone:941-330-6167
Mailing Address - Fax:
Practice Address - Street 1:17435 US HIGHWAY 441 STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6750
Practice Address - Country:US
Practice Address - Phone:352-434-0455
Practice Address - Fax:352-385-7264
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician