Provider Demographics
NPI:1942080858
Name:KOENEN, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOENEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3473 RIDER TRL S
Mailing Address - Street 2:
Mailing Address - City:EARTH CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63045-1110
Mailing Address - Country:US
Mailing Address - Phone:314-328-0088
Mailing Address - Fax:
Practice Address - Street 1:340 FESTUS CENTRE DRIVE
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-948-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021028858237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist