Healthcare Provider Details

I. General information

NPI: 1912464561
Provider Name (Legal Business Name): KATHY ANN PUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REVERE DR STE 120
NORTHBROOK IL
60062-8005
US

IV. Provider business mailing address

704 EDGEWATER DR
MINOOKA IL
60447-8928
US

V. Phone/Fax

Practice location:
  • Phone: 844-247-7222
  • Fax: 847-348-3706
Mailing address:
  • Phone: 708-577-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: