Provider Demographics
NPI:1679164511
Name:KONUCH, KASSANDRA A (BS, CADC, LCDP)
Entity type:Individual
Prefix:MS
First Name:KASSANDRA
Middle Name:A
Last Name:KONUCH
Suffix:
Gender:F
Credentials:BS, CADC, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 JENNIFER DR
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2346
Mailing Address - Country:US
Mailing Address - Phone:401-261-7900
Mailing Address - Fax:
Practice Address - Street 1:1130 TEN ROD RD BLDG F
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-261-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00817101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)