Provider Demographics
NPI:1184291569
Name:KOLTZ, MICHAEL (LCSW-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOLTZ
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2622
Mailing Address - Country:US
Mailing Address - Phone:443-974-8191
Mailing Address - Fax:
Practice Address - Street 1:1431 HARVEY AVE
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-2622
Practice Address - Country:US
Practice Address - Phone:443-974-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health