Provider Demographics
NPI:1467411892
Name:KULICK, PAUL JAMES (ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JAMES
Last Name:KULICK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5282 CONGVALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109
Mailing Address - Country:US
Mailing Address - Phone:815-399-1975
Mailing Address - Fax:815-399-3207
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:STE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:815-399-1975
Practice Address - Fax:815-399-3207
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer