Healthcare Provider Details

I. General information

NPI: 1831410869
Provider Name (Legal Business Name): KATHERINE KONCILJA M.A., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MILLER RD STE 7
AVON LAKE OH
44012-1013
US

IV. Provider business mailing address

215 MILLER RD STE 7
AVON LAKE OH
44012-1013
US

V. Phone/Fax

Practice location:
  • Phone: 440-742-1661
  • Fax: 440-653-9576
Mailing address:
  • Phone: 440-742-1661
  • Fax: 440-653-9576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE1000011
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number090037
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: