=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487615944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E KOETTING LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 W 24TH ST SUITE 906
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-741-2606
-----------------------------------------------------
Fax | 212-741-2606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 W 64TH ST SUITE 11D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-6734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-877-6523
-----------------------------------------------------
Fax | 212-741-2606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R049450
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------