Basic Information
| Provider Information | |||||||||
| NPI: | 1992120562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONOPKA | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3250 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481629297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343843402 | ||||||||
| FaxNumber: | 7343843158 | ||||||||
| Practice Location | |||||||||
| Address1: | 43825 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343973088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2014 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.