Provider Demographics
NPI:1477193001
Name:KUTSUKOS, ALYSSA STAVROULA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:STAVROULA
Last Name:KUTSUKOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 JEWELL ST SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-8217
Mailing Address - Country:US
Mailing Address - Phone:772-812-4251
Mailing Address - Fax:
Practice Address - Street 1:1802 S FISKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3007
Practice Address - Country:US
Practice Address - Phone:321-446-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLIMH24704101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health