Healthcare Provider Details

I. General information

NPI: 1265748834
Provider Name (Legal Business Name): JANELLEN KUCHAREK M.A., L.L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W MAIN ST SUITE E
GAYLORD MI
49735-1817
US

IV. Provider business mailing address

PO BOX 325
WATERS MI
49797-0325
US

V. Phone/Fax

Practice location:
  • Phone: 989-390-4256
  • Fax:
Mailing address:
  • Phone: 989-390-4256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010552
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: