Provider Demographics
NPI:1053057984
Name:KOEHLER, ANNETTE ILENE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:ILENE
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7430 S HARVEST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3110
Mailing Address - Country:US
Mailing Address - Phone:801-502-5672
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD STE 600
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4389
Practice Address - Country:US
Practice Address - Phone:877-504-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician