Basic Information
| Provider Information | |||||||||
| NPI: | 1043683857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUCKO | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152349101 | ||||||||
| FaxNumber: | 7152340748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1016 LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152349101 | ||||||||
| FaxNumber: | 7152340748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2015 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4122-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.