MEDICARE: DR. SUSAN IRENE KOENIG LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT 24989	CA

General Provider Information

NPI Number	:	1255340576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN IRENE KOENIG LMFT

Provider Business Mailing Address
First Line	:	4711 NEW YORK AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-5834
Country	:	US
Telephone Number	:	916-967-4956
Fax Number	:	916-965-6212

Provider Business Practice Location Address
First Line	:	4711 NEW YORK AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-5834
Country	:	US
Telephone Number	:	916-967-4956
Fax Number	:	916-965-6212

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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