Provider Demographics
NPI:1225388697
Name:MICHELLE KUKLA PSYD PC
Entity Type:Organization
Organization Name:MICHELLE KUKLA PSYD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-560-6653
Mailing Address - Street 1:800 E NORTHWEST HWY STE 500
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-6511
Mailing Address - Country:US
Mailing Address - Phone:708-560-6653
Mailing Address - Fax:
Practice Address - Street 1:800 E NORTHWEST HWY STE 500
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-6511
Practice Address - Country:US
Practice Address - Phone:708-560-6653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty