1528281425 NPI number — STRUCTURED FAMILY INTERVENTIONS, LLC

Table of content: MRS. KELLY MARIE KOLB LMT (NPI 1174020440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528281425 NPI number — STRUCTURED FAMILY INTERVENTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STRUCTURED FAMILY INTERVENTIONS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528281425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6011 FAYETTEVILLE RD
Provider Second Line Business Mailing Address:
SUITE 104-C
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27713-6248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-416-0800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6011 FAYETTEVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 104-C
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27713-6248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-416-0800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKLEAR
Authorized Official First Name:
DORIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
919-416-0800

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3418578 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3418775 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302972H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301584 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302972V , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5950736 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6008042 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302972G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302972 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302972Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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