MEDICARE: MS. MARY THERESE KOLLES MA, PRP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	171613	MN

General Provider Information

NPI Number	:	1821187543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY THERESE KOLLES MA, PRP

Provider Business Mailing Address
First Line	:	1049 GLEN PAUL CT
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-8114
Country	:	US
Telephone Number	:	612-435-7210
Fax Number	:	612-435-7201

Provider Business Practice Location Address
First Line	:	1313 5TH ST SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4504
Country	:	US
Telephone Number	:	612-435-7210
Fax Number	:	612-435-7201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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