MEDICARE: MRS. CHARLOTTE A KOINER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	12672	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84441L	OTHER	TX	BLUECROSS/BLUESHIELDOF TX

General Provider Information

NPI Number	:	1417045220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARLOTTE A KOINER

Provider Business Mailing Address
First Line	:	21714 HARDY OAK BLVD
Second Line	:	SUITE #104
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4838
Country	:	US
Telephone Number	:	210-490-9062
Fax Number	:	210-490-8843

Provider Business Practice Location Address
First Line	:	21714 HARDY OAK BLVD
Second Line	:	SUITE #104
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4838
Country	:	US
Telephone Number	:	210-490-9062
Fax Number	:	210-490-8843

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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