Provider Demographics
NPI:1073131033
Name:KOELLMANN, SANDRA M (ASW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:KOELLMANN
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3767 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-2599
Practice Address - Country:US
Practice Address - Phone:619-584-4010
Practice Address - Fax:619-278-0770
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA862011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical