Provider Demographics
NPI:1295821171
Name:KUKOLECK, KEVIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:KUKOLECK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 MAPLECREST AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-3524
Mailing Address - Country:US
Mailing Address - Phone:773-573-5393
Mailing Address - Fax:
Practice Address - Street 1:3591 RESERVE COMMONS DR STE 301
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5334
Practice Address - Country:US
Practice Address - Phone:330-764-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006575103TC0700X
CA29905103TC0700X
OH08214103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212919Medicare PIN