Healthcare Provider Details

I. General information

NPI: 1538698147
Provider Name (Legal Business Name): STANLEY D KOLPAK II PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N 13TH ST
ELMA WA
98541-9330
US

IV. Provider business mailing address

604 N 13TH ST
ELMA WA
98541-9330
US

V. Phone/Fax

Practice location:
  • Phone: 360-470-4277
  • Fax: 360-532-8786
Mailing address:
  • Phone: 360-470-4277
  • Fax: 360-532-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH1211688
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF61513857
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: