Provider Demographics
NPI:1629413893
Name:VUCKOVICH, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:VUCKOVICH
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 1:8102 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-3042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8102 W 119TH ST
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-3042
Practice Address - Country:US
Practice Address - Phone:708-738-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362706578Medicaid