Provider Demographics
NPI:1063196244
Name:KOLOCIN, SERENA BRALYN
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:BRALYN
Last Name:KOLOCIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7513 KENLEA AVE
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4321
Mailing Address - Country:US
Mailing Address - Phone:301-991-7227
Mailing Address - Fax:
Practice Address - Street 1:2501 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2505
Practice Address - Country:US
Practice Address - Phone:410-205-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician