Provider Demographics
NPI:1194431080
Name:KOELBL, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KOELBL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 E RACINE AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6456
Mailing Address - Country:US
Mailing Address - Phone:608-982-7232
Mailing Address - Fax:
Practice Address - Street 1:1422 E RACINE AVE APT 20
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-6456
Practice Address - Country:US
Practice Address - Phone:608-982-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12593-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty