=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548594468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA KONIG M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5875 BREMO RD SUITE 104
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23226-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-287-7463
-----------------------------------------------------
Fax | 804-287-7722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5875 BREMO RD SUITE 104
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23226-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-287-7463
-----------------------------------------------------
Fax | 804-287-7722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810004725
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------