Provider Demographics
NPI:1982183588
Name:KONVICKA, ERIK WADE
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:WADE
Last Name:KONVICKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COUNTY ROAD 132B
Mailing Address - Street 2:
Mailing Address - City:HALLETTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77964-3244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 KAHN ST
Practice Address - Street 2:
Practice Address - City:HALLETTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77964-2177
Practice Address - Country:US
Practice Address - Phone:361-798-3606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist