Provider Demographics
NPI:1659686418
Name:KONIECZKO, ROBIN M (MA,CCC,SLP)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:KONIECZKO
Suffix:
Gender:F
Credentials:MA,CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WESTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:ME
Mailing Address - Zip Code:04950-1227
Mailing Address - Country:US
Mailing Address - Phone:207-696-3323
Mailing Address - Fax:207-696-5631
Practice Address - Street 1:55 WESTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:ME
Practice Address - Zip Code:04950-1227
Practice Address - Country:US
Practice Address - Phone:207-696-3323
Practice Address - Fax:207-696-5631
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME999808537Medicaid
ME999808537Medicaid