Healthcare Provider Details

I. General information

NPI: 1891046595
Provider Name (Legal Business Name): LUKE KOLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

454 HELEN ST
PASO ROBLES CA
93446-3202
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4711
  • Fax:
Mailing address:
  • Phone: 805-712-9154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number36547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: