Provider Demographics
NPI:1043869795
Name:KUCK, EUGENE KENNETH JR
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:KENNETH
Last Name:KUCK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MARENGO RD
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3424
Mailing Address - Country:US
Mailing Address - Phone:815-404-7795
Mailing Address - Fax:
Practice Address - Street 1:4209 W SHAMROCK LN
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8700
Practice Address - Country:US
Practice Address - Phone:815-344-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty