Provider Demographics
NPI:1841338548
Name:RICHARD A KOLOTKIN PHD PA
Entity type:Organization
Organization Name:RICHARD A KOLOTKIN PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOLOTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-280-2484
Mailing Address - Street 1:403 CENTER AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1975
Mailing Address - Country:US
Mailing Address - Phone:701-280-2484
Mailing Address - Fax:701-232-2220
Practice Address - Street 1:403 CENTER AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1975
Practice Address - Country:US
Practice Address - Phone:701-280-2484
Practice Address - Fax:701-232-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDND 108OtherPSYCHOLOGIST CLINICAL
MNMN LPOtherPSYCHOLOGIST CLINICAL