Provider Demographics
NPI:1821137159
Name:COENEN, CRAIG PATRICK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:PATRICK
Last Name:COENEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 S WAVERLY AVE SUITE D
Mailing Address - Street 2:#101
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1497
Mailing Address - Country:US
Mailing Address - Phone:417-315-4962
Mailing Address - Fax:888-884-4101
Practice Address - Street 1:2053 S WAVERLY AVE STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2497
Practice Address - Country:US
Practice Address - Phone:417-315-4962
Practice Address - Fax:888-884-4101
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024663101YP2500X
MO2016035928103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499955409Medicaid