Provider Demographics
NPI:1457448185
Name:PRABUCKI, KENNETH M (MA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:PRABUCKI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2274 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-2633
Mailing Address - Country:US
Mailing Address - Phone:440-526-3030
Mailing Address - Fax:440-838-6085
Practice Address - Street 1:10000 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:440-838-6085
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health