Provider Demographics
NPI:1467742429
Name:KOEHLER, MARY CALLAHAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CALLAHAN
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-1709
Mailing Address - Country:US
Mailing Address - Phone:585-615-3603
Mailing Address - Fax:
Practice Address - Street 1:545 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1221
Practice Address - Country:US
Practice Address - Phone:585-615-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007651-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist