Provider Demographics
NPI:1073044053
Name:KOEHLER, GREG (RADT1)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 COLGATE DR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-6306
Mailing Address - Country:US
Mailing Address - Phone:610-314-3213
Mailing Address - Fax:
Practice Address - Street 1:2332 COLGATE DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6306
Practice Address - Country:US
Practice Address - Phone:610-314-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician