Provider Demographics
NPI:1639686041
Name:KONIECZNY, TARA MARIE
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:MARIE
Last Name:KONIECZNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06060-1104
Mailing Address - Country:US
Mailing Address - Phone:860-978-7768
Mailing Address - Fax:
Practice Address - Street 1:200 SEABURY DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2650
Practice Address - Country:US
Practice Address - Phone:860-286-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001739224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant