Provider Demographics
NPI:1487065496
Name:KONCEWICZ, GARY SEAN (DPT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:SEAN
Last Name:KONCEWICZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8059 MITCHELL LN
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216
Mailing Address - Country:US
Mailing Address - Phone:706-845-9383
Mailing Address - Fax:706-845-9382
Practice Address - Street 1:1805 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3871
Practice Address - Country:US
Practice Address - Phone:706-845-9383
Practice Address - Fax:706-845-9382
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist