Provider Demographics
NPI:1154451649
Name:KOENIG, SANDRA (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:KOENIG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:NETTLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2611 EUBANK BLVD NE
Mailing Address - Street 2:AZTEC COMPLEX
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1312
Mailing Address - Country:US
Mailing Address - Phone:505-298-6752
Mailing Address - Fax:
Practice Address - Street 1:SAN JUAN BOARD OF COOPERATIVE EDUCATION SERVICES (BOCES
Practice Address - Street 2:701 CAMINO DEL RIO SUITE 221
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-247-3261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM948235Z00000X
CO24379959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20789033Medicaid