Provider Demographics
NPI:1538181169
Name:KOLOCEK, ANN K (PHD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:K
Last Name:KOLOCEK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FRONT ST
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1667
Mailing Address - Country:US
Mailing Address - Phone:920-885-2780
Mailing Address - Fax:920-885-2788
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:SUITE 3D
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1667
Practice Address - Country:US
Practice Address - Phone:920-885-2780
Practice Address - Fax:920-885-2788
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1935057103TC0700X
WI1935-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39689100Medicaid
WI82804005Medicare ID - Type Unspecified