Provider Demographics
NPI:1477876480
Name:KONCELIK, KATHERINE (CBD, CPD, CLC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KONCELIK
Suffix:
Gender:F
Credentials:CBD, CPD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1826
Mailing Address - Country:US
Mailing Address - Phone:631-581-1066
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-581-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty