Provider Demographics
NPI:1407918998
Name:KOLLER, TIMOTHY JOHN (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:KOLLER
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-1127
Mailing Address - Country:US
Mailing Address - Phone:920-457-6750
Mailing Address - Fax:920-457-8350
Practice Address - Street 1:401 5TH ST
Practice Address - Street 2:STE 235
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5470
Practice Address - Country:US
Practice Address - Phone:715-849-3311
Practice Address - Fax:715-849-8414
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2649-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39756000Medicaid