Healthcare Provider Details

I. General information

NPI: 1477603421
Provider Name (Legal Business Name): DIANE M. KUKULIS ACSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4798 WENMAR DR
SAGINAW MI
48604-2843
US

IV. Provider business mailing address

4798 WENMAR DR
SAGINAW MI
48604-2843
US

V. Phone/Fax

Practice location:
  • Phone: 989-790-2005
  • Fax: 989-686-2603
Mailing address:
  • Phone: 989-790-2005
  • Fax: 989-686-2603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801072048
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: