Provider Demographics
NPI:1497589766
Name:KONIECZNY, ELLIE BLAIR (BA)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:BLAIR
Last Name:KONIECZNY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 STINSON RD
Mailing Address - Street 2:
Mailing Address - City:HERRON
Mailing Address - State:MI
Mailing Address - Zip Code:49744-9620
Mailing Address - Country:US
Mailing Address - Phone:989-255-0569
Mailing Address - Fax:
Practice Address - Street 1:318 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-2306
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator