Provider Demographics
NPI:1295459949
Name:KOLICH, AMANDA MARIE (LPC-IT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:KOLICH
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1652
Mailing Address - Country:US
Mailing Address - Phone:414-651-8612
Mailing Address - Fax:
Practice Address - Street 1:101 W EVERGREEN PKWY STE 1
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4083
Practice Address - Country:US
Practice Address - Phone:262-475-5684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7124226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor