Healthcare Provider Details

I. General information

NPI: 1497771497
Provider Name (Legal Business Name): MICKEY KUCAK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 WASHINGTON AVE STE 100
MOUNT PLEASANT WI
53406-3705
US

IV. Provider business mailing address

9000 W WISCONSIN AVE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 262-633-3591
  • Fax: 262-633-2619
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2600-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: