Healthcare Provider Details

I. General information

NPI: 1396393575
Provider Name (Legal Business Name): MICHAEL KUCSERIK LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PLEASANTVIEW ST
MONTPELIER VT
05602-3718
US

IV. Provider business mailing address

45 PLEASANTVIEW ST
MONTPELIER VT
05602-3718
US

V. Phone/Fax

Practice location:
  • Phone: 802-585-6137
  • Fax:
Mailing address:
  • Phone: 802-585-6137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0134082
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: