Provider Demographics
NPI:1801234406
Name:KULISH, ADAM BENJAMIN (PT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:BENJAMIN
Last Name:KULISH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 S MERCY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0429
Mailing Address - Country:US
Mailing Address - Phone:480-963-2400
Mailing Address - Fax:480-762-1992
Practice Address - Street 1:3485 S MERCY RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0429
Practice Address - Country:US
Practice Address - Phone:480-963-2400
Practice Address - Fax:480-726-1992
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist