Provider Demographics
NPI:1144259375
Name:CUCULI, KIM M (OTR)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:CUCULI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GENEVA PKWY N STE 3
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-5701
Mailing Address - Country:US
Mailing Address - Phone:262-248-9902
Mailing Address - Fax:262-249-9419
Practice Address - Street 1:800 GENEVA PKWY N STE 3
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147
Practice Address - Country:US
Practice Address - Phone:262-248-9902
Practice Address - Fax:262-248-9419
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1594225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01063884OtherRR MEDICARE
WI40808500Medicaid
WIS71304Medicare UPIN
WI40808500Medicaid
WI46236-0077Medicare PIN