Provider Demographics
NPI:1376756916
Name:KOERNER, BEVERLY ANN (LCS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:KOERNER
Suffix:
Gender:F
Credentials:LCS
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:MELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS214641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherMEDICARE GROUP ID#
CALCS 21464OtherCALIFORNIA
CAZZZ31989ZMedicare PIN