Provider Demographics
NPI:1902638653
Name:KOELKER, TANYA RENEE (LCPC)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENEE
Last Name:KOELKER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LINCOLN PLACE CT STE 102
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5876
Mailing Address - Country:US
Mailing Address - Phone:618-722-9616
Mailing Address - Fax:
Practice Address - Street 1:12 SUNDEW DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-4356
Practice Address - Country:US
Practice Address - Phone:618-581-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011458101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional