Healthcare Provider Details

I. General information

NPI: 1518004241
Provider Name (Legal Business Name): MAREK KUKULKA LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

896 ASYLUM AVE
HARTFORD CT
06105-1901
US

IV. Provider business mailing address

34 WALTER DR
GRISWOLD CT
06351-3539
US

V. Phone/Fax

Practice location:
  • Phone: 860-493-1841
  • Fax:
Mailing address:
  • Phone: 860-376-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000790
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: