Provider Demographics
NPI:1679845465
Name:KOEHNE, GRETCHEN A (LCPC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:A
Last Name:KOEHNE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:A
Other - Last Name:TIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1301 WAVERLY DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-2949
Mailing Address - Country:US
Mailing Address - Phone:618-960-5750
Mailing Address - Fax:618-288-0737
Practice Address - Street 1:2016 VADALABENE DR STE A
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-6901
Practice Address - Country:US
Practice Address - Phone:618-960-5750
Practice Address - Fax:618-288-0737
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional