Provider Demographics
NPI:1790422681
Name:KOEHLY, VICKIE (SLP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:KOEHLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 CONCEPCION AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-5003
Mailing Address - Country:US
Mailing Address - Phone:619-607-8915
Mailing Address - Fax:
Practice Address - Street 1:718 CONCEPCION AVE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-5003
Practice Address - Country:US
Practice Address - Phone:619-607-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist