Provider Demographics
NPI:1538608773
Name:KUDLAWIEC, CAROLINA
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:
Last Name:KUDLAWIEC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11554 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2644
Mailing Address - Country:US
Mailing Address - Phone:586-558-0185
Mailing Address - Fax:586-558-7128
Practice Address - Street 1:29150 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1218
Practice Address - Country:US
Practice Address - Phone:586-779-0911
Practice Address - Fax:586-779-0907
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002857225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant