Provider Demographics
NPI:1184160657
Name:KOLB, REBECCA LEE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:KOLB
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1345
Mailing Address - Country:US
Mailing Address - Phone:608-213-0158
Mailing Address - Fax:
Practice Address - Street 1:4200 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3208
Practice Address - Country:US
Practice Address - Phone:269-459-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-16-23478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst