Provider Demographics
NPI:1467564641
Name:KOENIG, MARTHA LEE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:LEE
Last Name:KOENIG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3536
Mailing Address - Country:US
Mailing Address - Phone:978-621-6220
Mailing Address - Fax:
Practice Address - Street 1:72 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10154301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10303007Medicaid
MAP04575Medicare ID - Type Unspecified