Provider Demographics
NPI:1487817789
Name:KOEHN, PETER (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:KOEHN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 W BERTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1738
Mailing Address - Country:US
Mailing Address - Phone:630-865-1352
Mailing Address - Fax:
Practice Address - Street 1:5017 W BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1738
Practice Address - Country:US
Practice Address - Phone:630-865-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007428103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8888Medicare PIN
ILDV2555Medicare PIN
ILIL7217Medicare PIN
ILIL7562Medicare PIN