Provider Demographics
NPI:1801281746
Name:KONSEWICZ, AMY KRISTINE
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:KRISTINE
Last Name:KONSEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4723 ALMA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1101
Mailing Address - Country:US
Mailing Address - Phone:217-836-9787
Mailing Address - Fax:
Practice Address - Street 1:107 MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1633
Practice Address - Country:US
Practice Address - Phone:314-435-6848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017694104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker