1649483363 NPI number — DR. LAURIE LYNN KOENIG PSYD

Table of content: DR. LAURIE LYNN KOENIG PSYD (NPI 1649483363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649483363 NPI number — DR. LAURIE LYNN KOENIG PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOENIG
Provider First Name:
LAURIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLDERNESS
Provider Other First Name:
LAURIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649483363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1344 REDWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULF BREEZE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32563-5600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-428-0506
Provider Business Mailing Address Fax Number:
866-214-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2026 17TH ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93301-4251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-861-1134
Provider Business Practice Location Address Fax Number:
661-325-3030
Provider Enumeration Date:
05/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY19935 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)