Basic Information
| Provider Information | |||||||||
| NPI: | 1922194612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONWIAK | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JUNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEINRICH/MADDOCKS | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | JUNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530405 | ||||||||
| FaxNumber: | 5867530404 | ||||||||
| Practice Location | |||||||||
| Address1: | 22151 MOROSS RD | ||||||||
| Address2: | PB1 SUITE 334 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133438784 | ||||||||
| FaxNumber: | 3133437449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301004046 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.