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General NPI Number Information
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NPI Number | 1104782549
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Entity Type | Individual
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Provider Name | CARLY KOENIG
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Gender | Female
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Dates
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Enumeration Date | 12/30/2025
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Last Update Date | 12/30/2025
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Provider Practice Location Address
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Address Line | 1060 W PERIMETER RD
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City | JB ANDREWS
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State | MD
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Zip | 20762-6602
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Country | US
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Telephone | 240-857-8964
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Fax |
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Provider Business Mailing Address
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Address Line | 8117 BURHOLME AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19111-1810
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PS020645
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License Number State | PA
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