Provider Demographics
NPI:1811566714
Name:KOEHLER, MALAKI SCOTT
Entity type:Individual
Prefix:MR
First Name:MALAKI
Middle Name:SCOTT
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 WINDMILL TRL
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-0476
Mailing Address - Country:US
Mailing Address - Phone:623-225-5317
Mailing Address - Fax:
Practice Address - Street 1:700 N SAINT MARYS ST STE 1400
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-3535
Practice Address - Country:US
Practice Address - Phone:847-465-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-169147106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty