Healthcare Provider Details

I. General information

NPI: 1265843825
Provider Name (Legal Business Name): MICHAEL KUKLICA LCDC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 COLEGATE DR
MARIETTA OH
45750-2363
US

IV. Provider business mailing address

PO BOX 1385
PARKERSBURG WV
26102-1385
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-0930
  • Fax: 740-376-0933
Mailing address:
  • Phone: 304-422-1405
  • Fax: 304-485-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDC081080-2
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: