Healthcare Provider Details

I. General information

NPI: 1245719210
Provider Name (Legal Business Name): SARA GABRIELLE KUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 JOHN ST
AMITYVILLE NY
11701-2930
US

IV. Provider business mailing address

12 BROOKLYN AVE APT 409
VALLEY STREAM NY
11581-1286
US

V. Phone/Fax

Practice location:
  • Phone: 424-631-2900
  • Fax:
Mailing address:
  • Phone: 516-765-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103619
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: