Provider Demographics
NPI:1013002971
Name:KOLLER, SUSAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KOLLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 MONROE ST NE UNIT I98
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1873
Mailing Address - Country:US
Mailing Address - Phone:505-980-4563
Mailing Address - Fax:
Practice Address - Street 1:2819 RICHMOND DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1918
Practice Address - Country:US
Practice Address - Phone:505-883-3787
Practice Address - Fax:505-830-0106
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM662235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65824563Medicaid
NM10026768OtherLOVELACE HEALTH PLAN
NMQMYPR0072408OtherMOLINA HEALTH CARE