Provider Demographics
NPI:1275099905
Name:KONIECZKI, SAMANTHA (RBT)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:KONIECZKI
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5302 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4922
Mailing Address - Country:US
Mailing Address - Phone:863-937-8067
Mailing Address - Fax:
Practice Address - Street 1:5302 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4922
Practice Address - Country:US
Practice Address - Phone:863-937-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020984400Medicaid