Provider Demographics
NPI:1356776082
Name:KONIECZKA, STACEY LEE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LEE
Last Name:KONIECZKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W PENDLETON PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2950
Mailing Address - Country:US
Mailing Address - Phone:847-691-0391
Mailing Address - Fax:
Practice Address - Street 1:1111 W. DUNDEE RD.
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089
Practice Address - Country:US
Practice Address - Phone:847-691-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0113121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical