Provider Demographics
NPI:1245986991
Name:KOLLER, ANDRIA
Entity type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:KOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 2ND AVE APT F
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3681
Mailing Address - Country:US
Mailing Address - Phone:919-282-2967
Mailing Address - Fax:
Practice Address - Street 1:2655 S LAKE ERIE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-7350
Practice Address - Country:US
Practice Address - Phone:919-282-2967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12544516-6010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health