Provider Demographics
NPI:1396938932
Name:BOLKCOM, KARLA S (MA)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:S
Last Name:BOLKCOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7129 CROWN POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4038
Mailing Address - Country:US
Mailing Address - Phone:269-720-8734
Mailing Address - Fax:
Practice Address - Street 1:2019 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1630
Practice Address - Country:US
Practice Address - Phone:269-345-0909
Practice Address - Fax:269-345-4985
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1165794101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional