Provider Demographics
NPI:1639942451
Name:KONICKI, GINA MARIA (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIA
Last Name:KONICKI
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIA
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:406 LENOX RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5505
Mailing Address - Country:US
Mailing Address - Phone:610-505-5638
Mailing Address - Fax:
Practice Address - Street 1:406 LENOX RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5505
Practice Address - Country:US
Practice Address - Phone:610-505-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013177225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist