Healthcare Provider Details

I. General information

NPI: 1124654629
Provider Name (Legal Business Name): BERNADETTE KOEHLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 HANLEY RD
O FALLON MO
63368-6734
US

IV. Provider business mailing address

2025 HANLEY RD
O FALLON MO
63368-6734
US

V. Phone/Fax

Practice location:
  • Phone: 847-441-5593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: