Provider Demographics
NPI:1356024715
Name:KOLESNIKOV, IGOR
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:KOLESNIKOV
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 1:23123 50TH PL S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-3308
Mailing Address - Country:US
Mailing Address - Phone:253-670-0961
Mailing Address - Fax:
Practice Address - Street 1:101 ELLIOTT AVE W STE 500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4292
Practice Address - Country:US
Practice Address - Phone:253-670-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMC61586270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program