Healthcare Provider Details

I. General information

NPI: 1366080863
Provider Name (Legal Business Name): MELANIE KUKLIS N/A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: N/A N/A MELANIE GEOGHAN

II. Dates (important events)

Enumeration Date: 12/15/2019
Last Update Date: 12/15/2019
Certification Date: 12/15/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 PAQUATUCK AVE
EAST MORICHES NY
11940-1205
US

IV. Provider business mailing address

61 PAQUATUCK AVE
EAST MORICHES NY
11940-1205
US

V. Phone/Fax

Practice location:
  • Phone: 631-747-1737
  • Fax:
Mailing address:
  • Phone: 631-747-1737
  • 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: