Provider Demographics
NPI:1578989315
Name:KOEHLER, MARK EDWARD (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LAKES AT LITCHFIELD DR
Mailing Address - Street 2:REHAB DEPT
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-5502
Mailing Address - Country:US
Mailing Address - Phone:843-235-4071
Mailing Address - Fax:
Practice Address - Street 1:120 LAKES AT LITCHFIELD DR
Practice Address - Street 2:REHAB DEPT
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-5502
Practice Address - Country:US
Practice Address - Phone:843-235-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant