Healthcare Provider Details

I. General information

NPI: 1609553973
Provider Name (Legal Business Name): MADELYN ANNE KUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 CIRCLE DR
HOLMEN WI
54636-9187
US

IV. Provider business mailing address

1007 7TH ST S
LA CROSSE WI
54601-5477
US

V. Phone/Fax

Practice location:
  • Phone: 608-413-4825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: