Provider Demographics
NPI:1780849828
Name:KOLLER, TRACY LYNN (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:KOLLER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 LACEY AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07933-1406
Mailing Address - Country:US
Mailing Address - Phone:908-331-3730
Mailing Address - Fax:
Practice Address - Street 1:21 LACEY AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:NJ
Practice Address - Zip Code:07933-1406
Practice Address - Country:US
Practice Address - Phone:908-331-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051905001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical