Provider Demographics
NPI:1013231604
Name:KONICOV, MARC (LMHC)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:
Last Name:KONICOV
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3730
Mailing Address - Country:US
Mailing Address - Phone:781-245-1721
Mailing Address - Fax:
Practice Address - Street 1:16 GREEN ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3730
Practice Address - Country:US
Practice Address - Phone:781-245-1721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4279101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor