Provider Demographics
NPI:1427421023
Name:KOEBERNIK, KATIE (LPC-IT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:KOEBERNIK
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:KORDUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2691 VIOLET LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6080
Mailing Address - Country:US
Mailing Address - Phone:479-305-3081
Mailing Address - Fax:
Practice Address - Street 1:424 S MONROE AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4054
Practice Address - Country:US
Practice Address - Phone:920-445-0170
Practice Address - Fax:920-445-0174
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18335-130101YA0400X
WI2593-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427421023Medicaid