Provider Demographics
NPI:1215073101
Name:KOENIG, MARK ALAN (MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:KOENIG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 MASSACHUSETTS AVENUE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474
Mailing Address - Country:US
Mailing Address - Phone:781-646-7301
Mailing Address - Fax:
Practice Address - Street 1:742 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474
Practice Address - Country:US
Practice Address - Phone:781-646-7301
Practice Address - Fax:781-643-8726
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
99618201OtherNETWORK HLTH
MA1004745OtherNHP
MA1303287Medicaid
MA1303287OtherMBHP
MANP01332OtherBMC
MA703136OtherTUFTS
MAM18633OtherBCBS
MAM18633OtherBCBS