Provider Demographics
NPI:1780694349
Name:KONCSOL, STEPHEN WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WAYNE
Last Name:KONCSOL
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 1:13200 SW 32ND CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4603
Mailing Address - Country:US
Mailing Address - Phone:954-682-9728
Mailing Address - Fax:
Practice Address - Street 1:134 S DIXIE HWY STE 104
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-5423
Practice Address - Country:US
Practice Address - Phone:305-653-0098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2754103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRO4199Medicare UPIN
FL00075606Medicare ID - Type Unspecified