Provider Demographics
NPI:1518004241
Name:KUKULKA, MAREK (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MAREK
Middle Name:
Last Name:KUKULKA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WALTER DR
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-3539
Mailing Address - Country:US
Mailing Address - Phone:860-376-5475
Mailing Address - Fax:
Practice Address - Street 1:896 ASYLUM AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1901
Practice Address - Country:US
Practice Address - Phone:860-493-1841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000790106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1467545251Medicaid