Provider Demographics
NPI:1962666891
Name:KOENEN, KARESTAN CHASE (PHD)
Entity Type:Individual
Prefix:MS
First Name:KARESTAN
Middle Name:CHASE
Last Name:KOENEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LEONARD AVE
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1020
Mailing Address - Country:US
Mailing Address - Phone:617-432-4622
Mailing Address - Fax:617-432-3755
Practice Address - Street 1:24 LEONARD AVE
Practice Address - Street 2:APARTMENT 1
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1020
Practice Address - Country:US
Practice Address - Phone:617-432-4622
Practice Address - Fax:617-432-3755
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8122103TC0700X
NY014504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical