Provider Demographics
NPI:1689019838
Name:KUCALA, CASSIE LYNNE (PTA, DT)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:LYNNE
Last Name:KUCALA
Suffix:
Gender:F
Credentials:PTA, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9860 PARRISH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8764
Mailing Address - Country:US
Mailing Address - Phone:815-592-9849
Mailing Address - Fax:
Practice Address - Street 1:9860 PARRISH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8764
Practice Address - Country:US
Practice Address - Phone:815-592-9849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225200000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist