Provider Demographics
NPI:1770664526
Name:KOYM, KENNETH (MFT, CE PROVIDER)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KOYM
Suffix:
Gender:M
Credentials:MFT, CE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9704 MONARCH LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-5840
Mailing Address - Country:US
Mailing Address - Phone:512-215-4798
Mailing Address - Fax:
Practice Address - Street 1:9704 MONARCH LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-5840
Practice Address - Country:US
Practice Address - Phone:512-215-4798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2646106H00000X
TX05-060-B (TEA)174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX562OtherAMBARASSNCEPRVDR #
TXLP0005392Other# MAYBE MEDICARE
TX00165OtherBCBS IN MEXICO & TX
TX02596810Medicaid
TX11824054OtherR & S NUMBER
TX1240OtherSTATEBARTX CE PRVDR #
TXLP0005392Other# MAYBE MEDICARE ?
TXLP0005392Medicare ID - Type Unspecified? MEDICARE