Provider Demographics
NPI:1851592216
Name:KOELLN, JAMES M (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:KOELLN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8509 151ST AVE
Mailing Address - Street 2:SUITE LM
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1301
Mailing Address - Country:US
Mailing Address - Phone:718-740-2067
Mailing Address - Fax:718-776-9806
Practice Address - Street 1:8509 151ST AVE
Practice Address - Street 2:SUITE LM
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1301
Practice Address - Country:US
Practice Address - Phone:718-740-2067
Practice Address - Fax:718-776-9806
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02145366Medicaid
NY02145366Medicaid
NYV8A95Medicare ID - Type UnspecifiedMEDICARE EMPIRE