Provider Demographics
NPI:1437126141
Name:KOENIG, NEDRA S (MA)
Entity Type:Individual
Prefix:
First Name:NEDRA
Middle Name:S
Last Name:KOENIG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:NEDRA
Other - Middle Name:S
Other - Last Name:KAVICKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1 E. MERCHANTS DRIVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543
Mailing Address - Country:US
Mailing Address - Phone:630-897-7492
Mailing Address - Fax:630-588-0502
Practice Address - Street 1:1 E. MERCHANTS DRIVE
Practice Address - Street 2:SUITE 303
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-897-7492
Practice Address - Fax:630-588-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166-000402106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232135OtherBLUE CROSS & BLUE SHIELD
IL1033869OtherCIGNA PROVIDER
IL780513OtherHOLMAN GROUP
5401280OtherAETNA
IL101621301OtherUBH
IL239972000OtherMAGELLAN PROVIDER
IL408124OtherVALUEOPTIONS