MEDICARE: CARLY KOENIG MA, NCC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1366239378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY KOENIG MA, NCC

Provider Business Mailing Address
First Line	:	4617 WOODLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3836
Country	:	US
Telephone Number	:	609-248-0631
Fax Number	:

Provider Business Practice Location Address
First Line	:	4617 WOODLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3836
Country	:	US
Telephone Number	:	267-254-0015
Fax Number	:

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

Provider Enumeration Date	:	04/22/2025
Last Update Date	:	06/16/2025

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