Healthcare Provider Details

I. General information

NPI: 1295178051
Provider Name (Legal Business Name): TERESA M KUCZMARSKI MS, LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA THORN

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N 6TH ST
WAUSAU WI
54403-4718
US

IV. Provider business mailing address

901 N 6TH ST
WAUSAU WI
54403-4718
US

V. Phone/Fax

Practice location:
  • Phone: 715-848-5022
  • Fax: 888-778-6750
Mailing address:
  • Phone: 715-848-5022
  • Fax: 888-778-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1369-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5972-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: