Provider Demographics
NPI:1124253968
Name:KONECHNY, MICHELE RENEE (LMP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENEE
Last Name:KONECHNY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24599 N CORBIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-8304
Mailing Address - Country:US
Mailing Address - Phone:208-964-5035
Mailing Address - Fax:
Practice Address - Street 1:24599 N CORBIN HILL RD
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-8304
Practice Address - Country:US
Practice Address - Phone:208-625-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist