Provider Demographics
NPI:1639104128
Name:KUCYK, NINA MARIE (PSYD, PCC-S, NCC)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:MARIE
Last Name:KUCYK
Suffix:
Gender:F
Credentials:PSYD, PCC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 BROAD AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2405
Mailing Address - Country:US
Mailing Address - Phone:330-639-0395
Mailing Address - Fax:330-454-9890
Practice Address - Street 1:2556 BROAD AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2405
Practice Address - Country:US
Practice Address - Phone:330-639-0395
Practice Address - Fax:330-454-9890
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000476946OtherANTHEM BCBS