Provider Demographics
NPI:1962924845
Name:KOEHLER, NICHOLAS MARK
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARK
Last Name:KOEHLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ELMWOOD AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3042
Mailing Address - Country:US
Mailing Address - Phone:585-271-0680
Mailing Address - Fax:
Practice Address - Street 1:3925 DOWNS DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3308
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021605225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist