Provider Demographics
NPI:1518976703
Name:KONCZAK, LEE (MSW)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:
Last Name:KONCZAK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 MANSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12275101YA0400X
WI6321231041C0700X
WI1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0000885740015Medicare ID - Type Unspecified