Healthcare Provider Details

I. General information

NPI: 1285969956
Provider Name (Legal Business Name): KIMBERLY DAWN KUCSIK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CALO LN
LAKE OZARK MO
65049-9208
US

IV. Provider business mailing address

130 CALO LN
LAKE OZARK MO
65049-9208
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2221
  • Fax: 573-365-2224
Mailing address:
  • Phone: 573-365-2221
  • Fax: 573-365-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW005728
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: