Provider Demographics
NPI:1255425971
Name:KONONCHUK, NINA (CSW)
Entity type:Individual
Prefix:MS
First Name:NINA
Middle Name:
Last Name:KONONCHUK
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 EAST 12TH STREET.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-336-6334
Mailing Address - Fax:
Practice Address - Street 1:1725 EAST 12TH STREET.
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-336-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0530001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01779831Medicaid
NYS41581Medicare UPIN
NY01779831Medicaid