Provider Demographics
NPI:1922194612
Name:KONWIAK, KATHLEEN JUNE (LLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JUNE
Last Name:KONWIAK
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:JUNE
Other - Last Name:HEINRICH/MADDOCKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:PB1 SUITE 334
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-8784
Practice Address - Fax:313-343-7449
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004046103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist