Provider Demographics
NPI:1134518905
Name:KOLICK, EMIL JAY VIII (MS)
Entity type:Individual
Prefix:MR
First Name:EMIL
Middle Name:JAY
Last Name:KOLICK
Suffix:VIII
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 ONWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-5928
Mailing Address - Country:US
Mailing Address - Phone:484-302-4425
Mailing Address - Fax:
Practice Address - Street 1:536 ONWARD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-5928
Practice Address - Country:US
Practice Address - Phone:484-302-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAI0147101Y00000X
PA4498101YA0400X
PA4759101YA0400X
FAC-K1308300929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4498OtherPCB CERTIFIED ALCOHOL AND DRUG COUNSELOR
PA4759OtherPCB ASSOCIATE PREVENTION SPECIALIST II
FAC-K1308300929OtherFORENSIC ADDICTIONS COUNSELOR: BREINING INSTITUTE
FAC-K1308300929OtherBREINING INSTITUTE: MASTERS LEVEL- REGISTERED ADDICTION SPECIALIST (M-RAS)
PA4759OtherPCB CERTIFIED CRIMINAL JUSTICE ADDICTIONS PROFESSIONAL
FAC-K1308300929OtherBREINING INSTITUTE: CERTIFIED CO-OCCURRING DISORDER SPECIALIST
802836OtherIC&RC CERTIFIED ALCOHOL AND DRUG COUNSELOR
PAI0147OtherPCB CERTIFIED INTERVENTION PROFESSIONAL
502300OtherIC&RC CERTIFIED CRIMINAL JUSTICE ADDICTIONS PROFESSIONAL