Provider Demographics
NPI:1508380866
Name:KOELSCH, THERESA LAURA (MA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LAURA
Last Name:KOELSCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 SALBUCK AVE
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-7137
Mailing Address - Country:US
Mailing Address - Phone:419-343-2123
Mailing Address - Fax:
Practice Address - Street 1:2271 SALBUCK AVE
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7137
Practice Address - Country:US
Practice Address - Phone:419-343-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.12621235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094740Medicaid