Healthcare Provider Details

I. General information

NPI: 1124120225
Provider Name (Legal Business Name): MICHAEL ANTHONY KOLLAR EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 SOUTHGATE DRIVE SUITE B
CHARLESTON SC
29407
US

IV. Provider business mailing address

1173 SOUTHGATE DRIVE SUITE B
CHARLESTON SC
29407
US

V. Phone/Fax

Practice location:
  • Phone: 843-769-5310
  • Fax: 843-571-6852
Mailing address:
  • Phone: 843-769-5310
  • Fax: 843-571-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number415
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number415
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: