Provider Demographics
NPI:1346076015
Name:KONICKI, KELLY ANN (LMT, CLT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KONICKI
Suffix:
Gender:
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 TREERIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-2830
Mailing Address - Country:US
Mailing Address - Phone:917-304-2672
Mailing Address - Fax:
Practice Address - Street 1:11180 STATE BRIDGE ROAD
Practice Address - Street 2:SUITE 404
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-7482
Practice Address - Country:US
Practice Address - Phone:678-871-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002856225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist