Basic Information
Provider Information | |||||||||
NPI: | 1215073101 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOENIG | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 742 MASSACHUSETTS AVENUE | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7816467301 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 742 MASSACHUSETTS AVE | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7816467301 | ||||||||
FaxNumber: | 7816438726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   | MA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 99618201 | 01 |   | NETWORK HLTH | OTHER | 1004745 | 01 | MA | NHP | OTHER | 1303287 | 05 | MA |   | MEDICAID | 1303287 | 01 | MA | MBHP | OTHER | NP01332 | 01 | MA | BMC | OTHER | 703136 | 01 | MA | TUFTS | OTHER | M18633 | 01 | MA | BCBS | OTHER |