Healthcare Provider Details

I. General information

NPI: 1396287918
Provider Name (Legal Business Name): RICHELLE KONCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18646 OXNARD ST
TARZANA CA
91356
US

IV. Provider business mailing address

18646 OXNARD ST
TARZANA CA
91356-1411
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1051
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSB94023119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: