Provider Demographics
NPI:1255664041
Name:MORRONGIELLO-KOENICK, SUSAN (LPCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MORRONGIELLO-KOENICK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2769
Mailing Address - Country:US
Mailing Address - Phone:575-740-2520
Mailing Address - Fax:575-894-0508
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2769
Practice Address - Country:US
Practice Address - Phone:575-740-2520
Practice Address - Fax:575-894-0508
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0148031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98557068Medicaid