Provider Demographics
NPI:1891345310
Name:FEESE, KONNOR (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:KONNOR
Middle Name:
Last Name:FEESE
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 SAN GABRIEL WAY UNIT 106
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-8034
Mailing Address - Country:US
Mailing Address - Phone:512-235-5899
Mailing Address - Fax:
Practice Address - Street 1:208 S NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-1894
Practice Address - Country:US
Practice Address - Phone:714-356-7066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114201106H00000X
CALMFT121564106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist