Provider Demographics
NPI:1790106060
Name:KOENEGSTEIN, NATHAN ALLEN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:ALLEN
Last Name:KOENEGSTEIN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GIDEON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6936
Mailing Address - Country:US
Mailing Address - Phone:618-214-3058
Mailing Address - Fax:
Practice Address - Street 1:597 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3935
Practice Address - Country:US
Practice Address - Phone:731-300-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000004821225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist