Provider Demographics
NPI:1750433850
Name:KOLODIN, JOHN LAURENCE (MSW LICSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LAURENCE
Last Name:KOLODIN
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTH HILLSIDE ROAD
Mailing Address - Street 2:SUITE 26
Mailing Address - City:SOUTH DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01373
Mailing Address - Country:US
Mailing Address - Phone:413-665-4158
Mailing Address - Fax:
Practice Address - Street 1:110 NORTH HILLSIDE ROAD
Practice Address - Street 2:SUITE 26
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373
Practice Address - Country:US
Practice Address - Phone:413-665-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10183321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852353Medicaid
P06297Medicare UPIN
MAP06297Medicare ID - Type Unspecified