Provider Demographics
NPI:1063584225
Name:KOLTIS, DEBRA A (MS,LPC,SAC,NCC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:KOLTIS
Suffix:
Gender:F
Credentials:MS,LPC,SAC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W10274 EDDY RD
Mailing Address - Street 2:
Mailing Address - City:THORP
Mailing Address - State:WI
Mailing Address - Zip Code:54771-7626
Mailing Address - Country:US
Mailing Address - Phone:715-497-6478
Mailing Address - Fax:
Practice Address - Street 1:W10274 EDDY RD
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-7626
Practice Address - Country:US
Practice Address - Phone:715-497-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15167101YA0400X
WI3438-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI409-78700Medicaid
WI93156OtherSECURITY HEALTH PLAN