Basic Information
| Provider Information | |||||||||
| NPI: | 1457998296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUKICH | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8227 BRECKSVILLE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441411363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405260468 | ||||||||
| FaxNumber: | 4405260454 | ||||||||
| Practice Location | |||||||||
| Address1: | 8227 BRECKSVILLE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441411363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405260468 | ||||||||
| FaxNumber: | 4405260454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2019 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1901933 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.