Provider Demographics
NPI:1831762202
Name:KOEPSELL-ROTH, CORRINE (AUD)
Entity type:Individual
Prefix:
First Name:CORRINE
Middle Name:
Last Name:KOEPSELL-ROTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-5020
Mailing Address - Country:US
Mailing Address - Phone:903-737-8800
Mailing Address - Fax:
Practice Address - Street 1:435 N MULFORD RD STE 10
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5100
Practice Address - Country:US
Practice Address - Phone:815-399-5279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
TX81069237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter