Provider Demographics
NPI:1427037696
Name:KOEHNE, PATRICK J (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:KOEHNE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FOUNTAINHEAD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5462
Mailing Address - Country:US
Mailing Address - Phone:910-977-3901
Mailing Address - Fax:910-426-3921
Practice Address - Street 1:103 FOUNTAINHEAD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5462
Practice Address - Country:US
Practice Address - Phone:910-977-3901
Practice Address - Fax:910-426-3921
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0004471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC49911OtherBLUE CROSS BLUE SHIELD
NC49911OtherBLUE CROSS BLUE SHIELD