Provider Demographics
NPI:1174144877
Name:KOEBERNICK, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:KOEBERNICK
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 1:8856 BRINDISI PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8856 BRINDISI PARK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5901
Practice Address - Country:US
Practice Address - Phone:847-975-8712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK140529235Z00000X
AZSLP12179235Z00000X
NVSP-2673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist