Provider Demographics
NPI:1417204660
Name:KOENIGSBERG, SHIRA
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:KOENIGSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 BRIARVISTA WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3640
Mailing Address - Country:US
Mailing Address - Phone:347-563-8783
Mailing Address - Fax:
Practice Address - Street 1:5887 GLENRIDGE DR STE 230
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-9929
Practice Address - Country:US
Practice Address - Phone:845-663-1683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0863231041C0700X
GACSW0069221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical