Provider Demographics
NPI:1760512206
Name:GOLLER, MEILAN V (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:MEILAN
Middle Name:V
Last Name:GOLLER
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 WINSTED BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6039
Mailing Address - Country:US
Mailing Address - Phone:517-780-4949
Mailing Address - Fax:
Practice Address - Street 1:3343 SPRING ARBOR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3992
Practice Address - Country:US
Practice Address - Phone:517-780-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010728341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7385238OtherAETNA PROVIDER ID