MEDICARE: ANDRIA KOLLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	12544516-6010	UT

General Provider Information

NPI Number	:	1245986991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRIA KOLLER

Provider Business Mailing Address
First Line	:	701 E 2ND AVE APT F
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-3681
Country	:	US
Telephone Number	:	919-282-2967
Fax Number	:

Provider Business Practice Location Address
First Line	:	2655 S LAKE ERIE DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-7350
Country	:	US
Telephone Number	:	919-282-2967
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2022
Last Update Date	:	02/22/2022

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