Healthcare Provider Details

I. General information

NPI: 1144259375
Provider Name (Legal Business Name): KIM M. CUCULI O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GENEVA PKWY N STE 3
LAKE GENEVA WI
53147
US

IV. Provider business mailing address

800 GENEVA PKWY N STE 3
LAKE GENEVA WI
53147-5701
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-9902
  • Fax: 262-248-9419
Mailing address:
  • Phone: 262-248-9902
  • Fax: 262-249-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1594
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: