Provider Demographics
NPI:1518204395
Name:KOENIGSBERG, JEFFREY (LISW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KOENIGSBERG
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 THRUPPS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3493
Mailing Address - Country:US
Mailing Address - Phone:505-670-7172
Mailing Address - Fax:
Practice Address - Street 1:813 THRUPPS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3493
Practice Address - Country:US
Practice Address - Phone:505-670-7172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-081191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical