Provider Demographics
NPI:1477603421
Name:KUKULIS, DIANE M (ACSW, LMSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:KUKULIS
Suffix:
Gender:F
Credentials:ACSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4798 WENMAR DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2843
Mailing Address - Country:US
Mailing Address - Phone:989-790-2005
Mailing Address - Fax:989-686-2603
Practice Address - Street 1:4798 WENMAR DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2843
Practice Address - Country:US
Practice Address - Phone:989-790-2005
Practice Address - Fax:989-686-2603
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010720481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N59460Medicare PIN