Healthcare Provider Details

I. General information

NPI: 1275979718
Provider Name (Legal Business Name): ELLIE LYNN KOEHN MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 E SANILAC RD
SANDUSKY MI
48471-1160
US

IV. Provider business mailing address

227 E SANILAC RD
SANDUSKY MI
48471-1160
US

V. Phone/Fax

Practice location:
  • Phone: 810-648-0330
  • Fax: 810-648-4338
Mailing address:
  • Phone: 810-648-0330
  • Fax: 810-648-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801091461
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: