Provider Demographics
NPI:1417445321
Name:KOERNER, MICHELLE R (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:KOERNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:DYKSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:1114 E COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-2359
Practice Address - Country:US
Practice Address - Phone:219-690-1048
Practice Address - Fax:219-690-1047
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013053A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist