MEDICARE: HEATHER KONICHEK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		OK

General Provider Information

NPI Number	:	1023600103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER KONICHEK

Provider Business Mailing Address
First Line	:	3801 NW 63RD ST BLDG 1
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1900
Country	:	US
Telephone Number	:	405-608-6077
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 NW 63RD ST BLDG 1
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1900
Country	:	US
Telephone Number	:	405-608-6077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	04/05/2022

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Directions to “ HEATHER KONICHEK ” Practice Location

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