Provider Demographics
NPI:1407042609
Name:KOEHN, THEODORA HART (MA AND PSYD)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:HART
Last Name:KOEHN
Suffix:
Gender:F
Credentials:MA AND PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17300 PRESTON RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5654
Mailing Address - Country:US
Mailing Address - Phone:214-435-4620
Mailing Address - Fax:
Practice Address - Street 1:17300 PRESTON RD
Practice Address - Street 2:SUITE 160
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5654
Practice Address - Country:US
Practice Address - Phone:214-435-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19497101YM0800X
CAPSY21181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical