Provider Demographics
NPI:1861614521
Name:KOLACZ, STEVEN D (LISW)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:D
Last Name:KOLACZ
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 SCHOLL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1571
Mailing Address - Country:US
Mailing Address - Phone:419-756-1717
Mailing Address - Fax:419-774-5955
Practice Address - Street 1:741 SCHOLL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1571
Practice Address - Country:US
Practice Address - Phone:419-756-1717
Practice Address - Fax:419-774-5955
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI55531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKOSW12372Medicare UPIN