Healthcare Provider Details

I. General information

NPI: 1134376908
Provider Name (Legal Business Name): MELISSA LOU KOERNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4684 ONTARIO MILLS PKWY STE 200
ONTARIO CA
91764-5151
US

IV. Provider business mailing address

1084 ROSEDALE RD
VENICE FL
34293-3322
US

V. Phone/Fax

Practice location:
  • Phone: 941-777-0868
  • Fax:
Mailing address:
  • Phone: 941-777-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11926
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW71193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: