Provider Demographics
NPI:1619568276
Name:KONICHEK, BREANNE
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:KONICHEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 E CROSSROADS
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-9011
Mailing Address - Country:US
Mailing Address - Phone:575-910-0268
Mailing Address - Fax:
Practice Address - Street 1:805 N RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4920
Practice Address - Country:US
Practice Address - Phone:575-622-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT-2025-0198225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOTA4415OtherNM OTA LICENSE