Provider Demographics
NPI:1174111462
Name:KOLSSAK, REBECCA LYNN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:KOLSSAK
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 1:1020 WOODMAN DR STE 330
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1410
Mailing Address - Country:US
Mailing Address - Phone:614-487-8758
Mailing Address - Fax:
Practice Address - Street 1:1020 WOODMAN DR STE 330
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1410
Practice Address - Country:US
Practice Address - Phone:614-487-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251S00000X
OHC.2103888101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health