Provider Demographics
NPI:1679748677
Name:KOLLATH, KENT THOMAS (CSAC, CSIT)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:THOMAS
Last Name:KOLLATH
Suffix:
Gender:M
Credentials:CSAC, CSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-3639
Mailing Address - Country:US
Mailing Address - Phone:920-254-6922
Mailing Address - Fax:
Practice Address - Street 1:2911 MAIN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-3639
Practice Address - Country:US
Practice Address - Phone:920-254-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15399-132101YA0400X
WI15401-133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)