Provider Demographics
NPI:1144613043
Name:KONCHELLAH, SATION
Entity Type:Individual
Prefix:
First Name:SATION
Middle Name:
Last Name:KONCHELLAH
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:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:NC
Mailing Address - Zip Code:27342
Mailing Address - Country:US
Mailing Address - Phone:336-494-5743
Mailing Address - Fax:
Practice Address - Street 1:2224 LACY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215
Practice Address - Country:US
Practice Address - Phone:336-494-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1068603103TS0200X
NCA11840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool