Provider Demographics
NPI:1194446542
Name:KOEGELENBERG, ESCA
Entity type:Individual
Prefix:
First Name:ESCA
Middle Name:
Last Name:KOEGELENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-4018
Mailing Address - Country:US
Mailing Address - Phone:903-918-5008
Mailing Address - Fax:
Practice Address - Street 1:250 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2853
Practice Address - Country:US
Practice Address - Phone:208-405-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty