Provider Demographics
NPI:1639475882
Name:KONIECZKA, LORI ANNE (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANNE
Last Name:KONIECZKA
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4260 LAUREL GLEN DR.
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-2723
Mailing Address - Country:US
Mailing Address - Phone:440-627-6158
Mailing Address - Fax:
Practice Address - Street 1:3518 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1951
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:216-320-8748
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 0800087 SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical