Provider Demographics
NPI:1306404165
Name:KONZ, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:KONZ
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 290
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-0290
Mailing Address - Country:US
Mailing Address - Phone:920-467-2223
Mailing Address - Fax:
Practice Address - Street 1:N6085 STATE ROAD 32
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-2341
Practice Address - Country:US
Practice Address - Phone:920-467-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1087875171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty