Provider Demographics
NPI:1578781233
Name:KOENIG, CRYSTAL CHADDERTON (MED)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CHADDERTON
Last Name:KOENIG
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11439 KABROON CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6920
Mailing Address - Country:US
Mailing Address - Phone:904-608-2848
Mailing Address - Fax:
Practice Address - Street 1:910 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6810
Practice Address - Country:US
Practice Address - Phone:904-360-7022
Practice Address - Fax:904-798-4545
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811897300Medicaid