Provider Demographics
NPI:1275080889
Name:KOENIG, LANCE (EDS)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:KOENIG
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 NORTH WASHINGTON AVE
Mailing Address - Street 2:PLEC DAKOTA STATE UNIVERSITY
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042
Mailing Address - Country:US
Mailing Address - Phone:605-256-5555
Mailing Address - Fax:
Practice Address - Street 1:820 NORTH WASHINGTON AVE
Practice Address - Street 2:PLEC DAKOTA STATE UNIVERSITY
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042
Practice Address - Country:US
Practice Address - Phone:605-256-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD72674-0103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool