Basic Information
| Provider Information | |||||||||
| NPI: | 1366711913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUKULSKI | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778976 | ||||||||
| FaxNumber: | 8473778803 | ||||||||
| Practice Location | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778976 | ||||||||
| FaxNumber: | 8473778803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2011 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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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 | 1041C0700X | 149.010289 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.