Provider Demographics
NPI:1396158903
Name:KOENIG, GWENDOLYN (LCMHC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:KOENIG
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 222
Mailing Address - Street 2:78 SOUTH MAIN ST.
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-8224
Mailing Address - Fax:802-747-7699
Practice Address - Street 1:78 SOUTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-8224
Practice Address - Fax:802-747-7699
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680078567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health