Provider Demographics
NPI:1710496567
Name:KOEBELE, SANTANA (EDS, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:SANTANA
Middle Name:
Last Name:KOEBELE
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:MS
Other - First Name:SANTANA
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS, NCSP
Mailing Address - Street 1:2408 CHISWICK DR APT 4
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2396
Mailing Address - Country:US
Mailing Address - Phone:217-530-9554
Mailing Address - Fax:
Practice Address - Street 1:104 S LYNN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:IL
Practice Address - Zip Code:61849-1205
Practice Address - Country:US
Practice Address - Phone:217-892-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1157386103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool