Provider Demographics
NPI:1063003143
Name:KONECZNY, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:KONECZNY
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 1:47 BRANDON RD APT 2
Mailing Address - Street 2:
Mailing Address - City:DUDLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01571-3544
Mailing Address - Country:US
Mailing Address - Phone:351-322-5459
Mailing Address - Fax:
Practice Address - Street 1:47 BRANDON RD APT 2
Practice Address - Street 2:
Practice Address - City:DUDLEY
Practice Address - State:MA
Practice Address - Zip Code:01571-3544
Practice Address - Country:US
Practice Address - Phone:351-322-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
U2N492W03403OtherANTHEM