Provider Demographics
NPI:1912362591
Name:KONOPACKI, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KONOPACKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 N EASTCAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2188
Mailing Address - Country:US
Mailing Address - Phone:650-739-5434
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR BLDG 3
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10299168-2501103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty