Provider Demographics
NPI:1669741021
Name:KUKICH, STEPHANIE LAYNE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAYNE
Last Name:KUKICH
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 1:284 EXECUTIVE PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:132 POPLAR GROVE CONNECTOR
Practice Address - Street 2:B
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5915
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor