Provider Demographics
NPI:1952458150
Name:KONECKY, MARK STANLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STANLEY
Last Name:KONECKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HODGKINS ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-1815
Mailing Address - Country:US
Mailing Address - Phone:978-283-0333
Mailing Address - Fax:978-283-0908
Practice Address - Street 1:6 HODGKINS ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-1815
Practice Address - Country:US
Practice Address - Phone:978-283-0333
Practice Address - Fax:978-283-0908
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05926OtherBLUE CROSS BLUE SHIELD