MEDICARE: TESSA FOX-KULAKOWSKI PHD, LCSW, M.ED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker	CW019436	PA
3	171M00000X	Case Manager/Care Coordinator
4	1041C0700X	Clinical Social Worker	CSW09926475	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		I DO NOT HAVE THESE NUMBERS.

General Provider Information

NPI Number	:	1558779801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESSA FOX-KULAKOWSKI PHD, LCSW, M.ED

Provider Business Mailing Address
First Line	:	7173 S HAVANA ST
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-3891
Country	:	US
Telephone Number	:	631-987-4970
Fax Number	:

Provider Business Practice Location Address
First Line	:	7173 S HAVANA ST
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-3891
Country	:	US
Telephone Number	:	631-987-4970
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2014
Last Update Date	:	01/31/2023

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