Provider Demographics
NPI:1669951588
Name:KOLOSIK, KATHLEEN JO (MS, QMHP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JO
Last Name:KOLOSIK
Suffix:
Gender:F
Credentials:MS, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 SW G ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:
Practice Address - Street 1:1700 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-0052
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health