Provider Demographics
NPI:1679900047
Name:KOLODCHIN, ROMAN JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:JOHN
Last Name:KOLODCHIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21056 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2760
Mailing Address - Country:US
Mailing Address - Phone:586-477-7472
Mailing Address - Fax:313-454-8447
Practice Address - Street 1:21056 DEAN ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2760
Practice Address - Country:US
Practice Address - Phone:586-477-7472
Practice Address - Fax:313-454-8447
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009313103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent