Provider Demographics
NPI:1679527287
Name:KOLLER, SUSAN COHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:COHN
Last Name:KOLLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:COHN
Other - Last Name:KOLLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:305 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4824
Mailing Address - Country:US
Mailing Address - Phone:865-588-7598
Mailing Address - Fax:865-588-6406
Practice Address - Street 1:305 WESTFIELD DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4824
Practice Address - Country:US
Practice Address - Phone:865-588-7598
Practice Address - Fax:865-588-6406
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1176103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3583343Medicare ID - Type UnspecifiedPSYCHOLOGIST