Provider Demographics
NPI:1043761778
Name:KONETZKA, LORIEN (BCBA)
Entity Type:Individual
Prefix:
First Name:LORIEN
Middle Name:
Last Name:KONETZKA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 S PARK RIDGE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8589
Mailing Address - Country:US
Mailing Address - Phone:812-822-0189
Mailing Address - Fax:
Practice Address - Street 1:322 DUPONT DR STE C
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1764
Practice Address - Country:US
Practice Address - Phone:317-334-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-16-23039103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011450Medicaid