MEDICARE: COLLEEN KUTCHKUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SL004849L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0017031120004	OTHER	PA	MEDICAL ASSISTANCE

General Provider Information

NPI Number	:	1205971660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN KUTCHKUS

Provider Business Mailing Address
First Line	:	RR 3 BOX 178B
Second Line	:
City	:	HARVEYS LAKE
State	:	PA
Zip	:	18618-9404
Country	:	US
Telephone Number	:	570-639-1369
Fax Number	:

Provider Business Practice Location Address
First Line	:	RR 3 BOX 178B
Second Line	:
City	:	HARVEYS LAKE
State	:	PA
Zip	:	18618-9404
Country	:	US
Telephone Number	:	570-639-1369
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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Directions to “ COLLEEN KUTCHKUS ” Practice Location

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