Healthcare Provider Details

I. General information

NPI: 1629799259
Provider Name (Legal Business Name): NICOLE E KUKLA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 LEONARD ST NE
GRAND RAPIDS MI
49505-5572
US

IV. Provider business mailing address

1560 LEONARD ST NW
GRAND RAPIDS MI
49504-2976
US

V. Phone/Fax

Practice location:
  • Phone: 616-278-7052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: