Provider Demographics
NPI:1861876773
Name:KOLEY, ROBERT JR (MED)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KOLEY
Suffix:JR
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 S 107TH AVE
Mailing Address - Street 2:200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4719
Mailing Address - Country:US
Mailing Address - Phone:402-213-4086
Mailing Address - Fax:402-333-5620
Practice Address - Street 1:920 S 107TH AVE
Practice Address - Street 2:200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4719
Practice Address - Country:US
Practice Address - Phone:402-213-4086
Practice Address - Fax:402-333-5620
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE522101Y00000X
NEP-1260101YA0400X
NE485101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional