Provider Demographics
NPI:1790188837
Name:KUCK, KELLY JO (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:KUCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W62N281 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012
Mailing Address - Country:US
Mailing Address - Phone:262-387-1722
Mailing Address - Fax:
Practice Address - Street 1:W62N281 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2737
Practice Address - Country:US
Practice Address - Phone:262-387-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist