Provider Demographics
NPI:1063171767
Name:KOLENICH, TRACY (LMFT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KOLENICH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 VALJEAN BLVD N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4630
Mailing Address - Country:US
Mailing Address - Phone:612-730-1558
Mailing Address - Fax:
Practice Address - Street 1:3640 TALMAGE CIRCLE
Practice Address - Street 2:SUITE 210C
Practice Address - City:VASNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:85503
Practice Address - Country:US
Practice Address - Phone:612-730-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist