Healthcare Provider Details

I. General information

NPI: 1689019838
Provider Name (Legal Business Name): CASSIE LYNNE KUCALA PTA, DT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9860 PARRISH ST
SAINT JOHN IN
46373-8764
US

IV. Provider business mailing address

9860 PARRISH ST
SAINT JOHN IN
46373-8764
US

V. Phone/Fax

Practice location:
  • Phone: 815-592-9849
  • Fax:
Mailing address:
  • Phone: 815-592-9849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: