Provider Demographics
NPI:1093869745
Name:KOERNER, MICHELLE J (MED)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:J
Last Name:KOERNER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PITTSFIELD CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2040
Mailing Address - Country:US
Mailing Address - Phone:314-330-3891
Mailing Address - Fax:314-830-6246
Practice Address - Street 1:12141 LADUE RD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-336-1097
Practice Address - Fax:314-830-6246
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21728101YP2500X
MO002488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499774008Medicaid