Provider Demographics
NPI:1285815084
Name:KOERNER, CINDY MARIE (CCC SLP)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:MARIE
Last Name:KOERNER
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:
Other - Last Name:STADELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-337-1122
Mailing Address - Fax:920-337-1126
Practice Address - Street 1:2801 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-337-1122
Practice Address - Fax:920-337-1126
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI346 154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42663400Medicaid