Healthcare Provider Details

I. General information

NPI: 1992316657
Provider Name (Legal Business Name): MICHELE KOLB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE HADDAD

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 J.B. WISE PLAZA
WATERTOWN NY
13601
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-788-7430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP112160
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: