Provider Demographics
NPI:1689326019
Name:KUCZEK, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:KUCZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-0324
Mailing Address - Country:US
Mailing Address - Phone:925-403-1012
Mailing Address - Fax:
Practice Address - Street 1:21 W PARK CT
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3431
Practice Address - Country:US
Practice Address - Phone:925-403-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123769106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist