Provider Demographics
NPI:1871632752
Name:KONIECZKA, MIKE (LCSW)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:KONIECZKA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S MOORLAND RD
Mailing Address - Street 2:SUITE #407
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6956
Mailing Address - Country:US
Mailing Address - Phone:262-789-7100
Mailing Address - Fax:
Practice Address - Street 1:1025 S MOORLAND RD
Practice Address - Street 2:SUITE #407
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6956
Practice Address - Country:US
Practice Address - Phone:262-789-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4043-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker