Provider Demographics
NPI:1841773488
Name:KOEHLER, CAMILLE PLASEK (PTA)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:PLASEK
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 SMITH LN
Mailing Address - Street 2:
Mailing Address - City:BRUCEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76630-3409
Mailing Address - Country:US
Mailing Address - Phone:254-722-1072
Mailing Address - Fax:
Practice Address - Street 1:8836 MARS DR
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3195
Practice Address - Country:US
Practice Address - Phone:254-420-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2042083225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant