Provider Demographics
NPI:1437646064
Name:DEISS, KONRAD
Entity Type:Individual
Prefix:
First Name:KONRAD
Middle Name:
Last Name:DEISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S DAVIS RD STE 900
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2609
Mailing Address - Country:US
Mailing Address - Phone:470-686-2225
Mailing Address - Fax:
Practice Address - Street 1:229 S DAVIS RD STE 900
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2609
Practice Address - Country:US
Practice Address - Phone:470-686-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)