Healthcare Provider Details

I. General information

NPI: 1679845465
Provider Name (Legal Business Name): GRETCHEN A KOEHNE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRETCHEN A TIMM MA

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 VADALABENE DR STE A
MARYVILLE IL
62062-6901
US

IV. Provider business mailing address

1301 WAVERLY DR
COLLINSVILLE IL
62234-2949
US

V. Phone/Fax

Practice location:
  • Phone: 618-960-5750
  • Fax: 618-288-0737
Mailing address:
  • Phone: 618-960-5750
  • Fax: 618-288-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180008111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: