Provider Demographics
NPI:1861823957
Name:CUKO, EVISA (MA, TLLP)
Entity Type:Individual
Prefix:MRS
First Name:EVISA
Middle Name:
Last Name:CUKO
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 AXTELL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4404
Mailing Address - Country:US
Mailing Address - Phone:248-613-5377
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:248-613-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016020103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist