Provider Demographics
NPI:1154448397
Name:KOLLER, AMENTHIA MEREDITH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMENTHIA
Middle Name:MEREDITH
Last Name:KOLLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TX
Mailing Address - Zip Code:76227-7663
Mailing Address - Country:US
Mailing Address - Phone:214-546-8382
Mailing Address - Fax:
Practice Address - Street 1:1417 AUGUSTA DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TX
Practice Address - Zip Code:76227-7663
Practice Address - Country:US
Practice Address - Phone:214-546-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP698235Z00000X
TX106038235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121468721Medicaid
TX106038Medicaid
AR5T451OtherBLUECROSS
TX106038OtherTEXAS SPEECH PATHOLOGY LICENSE