Provider Demographics
NPI:1710476437
Name:KOEHLER, IMELDA (LPC)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 S LINCOLN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-4290
Mailing Address - Country:US
Mailing Address - Phone:630-277-9608
Mailing Address - Fax:
Practice Address - Street 1:143 S LINCOLN AVE STE C
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-4290
Practice Address - Country:US
Practice Address - Phone:630-277-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013303101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85-0717906OtherGROUP TAX ID NUMBER