Healthcare Provider Details

I. General information

NPI: 1164076501
Provider Name (Legal Business Name): MELINDA KOEHNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 SOUTHEASTERN AVE
INDIANAPOLIS IN
46202-3948
US

IV. Provider business mailing address

1212 SOUTHEASTERN AVE
INDIANAPOLIS IN
46202-3948
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-2197
  • Fax:
Mailing address:
  • Phone: 888-824-2197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255R0406X
TaxonomyBlind Rehabilitation Specialist/Technologist
License Number1425191
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: