Provider Demographics
NPI:1578227419
Name:KONICKI, JUSTIN J (CDCA II, LSW)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:J
Last Name:KONICKI
Suffix:
Gender:M
Credentials:CDCA II, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:
Practice Address - Street 1:1830 W HIGH ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-9399
Practice Address - Country:US
Practice Address - Phone:937-637-3928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2310214104100000X
OHCDCA.164456101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker