Provider Demographics
NPI:1285700336
Name:KOLODZIEJ, MICHAEL KEVIN (MFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:KOLODZIEJ
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 MOUNT ACKERLY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4016
Mailing Address - Country:US
Mailing Address - Phone:858-302-3300
Mailing Address - Fax:858-292-9529
Practice Address - Street 1:5650 MOUNT ACKERLY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-4016
Practice Address - Country:US
Practice Address - Phone:858-302-3300
Practice Address - Fax:858-292-9529
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43472106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist