Provider Demographics
NPI:1003111733
Name:KOENIG, SUSAN BETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:BETH
Last Name:KOENIG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JOHNSON AVE
Mailing Address - Street 2:SUITE B7
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2614
Mailing Address - Country:US
Mailing Address - Phone:631-521-0966
Mailing Address - Fax:
Practice Address - Street 1:600 JOHNSON AVE
Practice Address - Street 2:SUITE B7
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2614
Practice Address - Country:US
Practice Address - Phone:631-521-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0782691041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool