Healthcare Provider Details

I. General information

NPI: 1356008643
Provider Name (Legal Business Name): REBECCA KUCKER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2021
Last Update Date: 11/21/2021
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 39TH PL APT 5E
SUNNYSIDE NY
11104-4418
US

IV. Provider business mailing address

4755 39TH PL APT 5E
SUNNYSIDE NY
11104-4418
US

V. Phone/Fax

Practice location:
  • Phone: 151-676-5045
  • Fax:
Mailing address:
  • Phone: 151-676-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103245
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: