Healthcare Provider Details

I. General information

NPI: 1538181169
Provider Name (Legal Business Name): ANN K KOLOCEK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FRONT ST SUITE 3D
BEAVER DAM WI
53916-1667
US

IV. Provider business mailing address

200 FRONT ST SUITE 3D
BEAVER DAM WI
53916-1667
US

V. Phone/Fax

Practice location:
  • Phone: 920-885-2780
  • Fax: 920-885-2788
Mailing address:
  • Phone: 920-885-2780
  • Fax: 920-885-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1935-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1935057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: