Provider Demographics
NPI: | 1760100747 |
---|---|
Name: | KUCIEMBA, JAMES NICHOLAS (PHD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JAMES |
Middle Name: | NICHOLAS |
Last Name: | KUCIEMBA |
Suffix: | |
Gender: | M |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 620 LONGMIRE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | CONROE |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77304-1819 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 936-443-9629 |
Mailing Address - Fax: | 855-443-9630 |
Practice Address - Street 1: | 620 LONGMIRE RD |
Practice Address - Street 2: | |
Practice Address - City: | CONROE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77304-1819 |
Practice Address - Country: | US |
Practice Address - Phone: | 936-443-9629 |
Practice Address - Fax: | 855-443-9630 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2022-08-16 |
Last Update Date: | 2023-11-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 39909 | 103TF0000X, 103TM1800X, 103TP2701X, 103T00000X, 103G00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TE1100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family |
No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No | 103TE1100X | Behavioral Health & Social Service Providers | Psychologist | Exercise & Sports |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 3770653-01 | Medicaid |