Healthcare Provider Details

I. General information

NPI: 1790241719
Provider Name (Legal Business Name): DANIELLE MARIE KOLB BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 6TH AVE
SOUTH CHARLESTON WV
25303-1231
US

IV. Provider business mailing address

117 CIRCLE DR
CROSS LANES WV
25313-1310
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-3383
  • Fax:
Mailing address:
  • Phone: 304-720-3383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-19-10593
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-19089
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: