MEDICARE: SUSAN KOLB MS, LPC

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	101YP2500X	Professional Counselor	C1831	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11627604	OTHER	OR	CAQH

General Provider Information

NPI Number	:	1396829602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KOLB MS, LPC

Provider Business Mailing Address
First Line	:	1468 NW ELGIN AVE
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-3032
Country	:	US
Telephone Number	:	541-550-8008
Fax Number	:	541-797-6898

Provider Business Practice Location Address
First Line	:	497 SW CENTURY DR STE 102
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-1167
Country	:	US
Telephone Number	:	541-550-8008
Fax Number	:	541-797-6898

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	03/21/2020

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