Provider Demographics
NPI:1861532673
Name:KOERNER, FRED E (PHD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:E
Last Name:KOERNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 BRADLEY STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-785-8052
Mailing Address - Fax:203-773-1271
Practice Address - Street 1:240 BRADLEY STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-785-8052
Practice Address - Fax:203-773-1271
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000704103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001134OtherMEDICARE