Provider Demographics
NPI:1043775299
Name:KOEHLER, CASSIDY LYNN
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:LYNN
Last Name:KOEHLER
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 1:12030 HOLBROOK DR APT 8
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-2949
Mailing Address - Country:US
Mailing Address - Phone:407-738-6886
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:813-920-9252
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB478510106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB478510Medicaid