Healthcare Provider Details

I. General information

NPI: 1205994837
Provider Name (Legal Business Name): ANGELA RENE' KOERWITZ LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 E MAIN ST
ROCHESTER IL
62563-9534
US

IV. Provider business mailing address

617 E MAIN ST
ROCHESTER IL
62563-9534
US

V. Phone/Fax

Practice location:
  • Phone: 217-414-4428
  • Fax: 217-414-4428
Mailing address:
  • Phone: 217-414-4428
  • Fax: 217-414-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-004014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: