Provider Demographics
NPI:1144565631
Name:KOENEKE, MICHELLE MARIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIA
Last Name:KOENEKE
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:DUMC 3868
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-684-3938
Mailing Address - Fax:919-681-9909
Practice Address - Street 1:DUMC 3868
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-684-3938
Practice Address - Fax:919-681-9909
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0079471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009250Medicaid