Healthcare Provider Details

I. General information

NPI: 1407358807
Provider Name (Legal Business Name): JONAH KUCINSKI-STEWART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11306 SIR WINSTON ST
SAN ANTONIO TX
78216-2467
US

IV. Provider business mailing address

11306 SIR WINSTON ST
SAN ANTONIO TX
78216-2467
US

V. Phone/Fax

Practice location:
  • Phone: 210-366-0049
  • Fax:
Mailing address:
  • Phone: 210-366-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-35114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: