Healthcare Provider Details

I. General information

NPI: 1871201442
Provider Name (Legal Business Name): CARLY KUCHAREK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3744 GULL RD
KALAMAZOO MI
49048-7642
US

IV. Provider business mailing address

3477 GULL RD
KALAMAZOO MI
49048-1281
US

V. Phone/Fax

Practice location:
  • Phone: 269-249-1490
  • Fax:
Mailing address:
  • Phone: 269-249-1490
  • 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: