Provider Demographics
NPI:1396106969
Name:KONICEK, RACHEL KIM
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:KIM
Last Name:KONICEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:KIM
Other - Last Name:FORTUNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA21054
Mailing Address - Street 1:8709 FOREST HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5474
Mailing Address - Country:US
Mailing Address - Phone:954-991-2600
Mailing Address - Fax:
Practice Address - Street 1:8709 FOREST HILLS BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5474
Practice Address - Country:US
Practice Address - Phone:954-991-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21054225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant