Provider Demographics
NPI:1942844253
Name:TUCCILLO, KIMBERLY PAIGE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:TUCCILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BETHANY RD STE 60
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1667
Mailing Address - Country:US
Mailing Address - Phone:732-888-3912
Mailing Address - Fax:
Practice Address - Street 1:1 BETHANY RD STE 60
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1667
Practice Address - Country:US
Practice Address - Phone:732-888-3912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00499800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1679957997Other1679957997