Healthcare Provider Details

I. General information

NPI: 1962126870
Provider Name (Legal Business Name): KARLI KUCKO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 S 1ST ST APT 104
AUSTIN TX
78704-7001
US

IV. Provider business mailing address

3501 S 1ST ST APT 104
AUSTIN TX
78704-7001
US

V. Phone/Fax

Practice location:
  • Phone: 405-714-6252
  • Fax:
Mailing address:
  • Phone: 405-714-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number85511
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: