Provider Demographics
NPI:1366080863
Name:KUKLIS, MELANIE (N/A)
Entity type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:
Last Name:KUKLIS
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MELANIE GEOGHAN
Mailing Address - Street 1:61 PAQUATUCK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1205
Mailing Address - Country:US
Mailing Address - Phone:631-747-1737
Mailing Address - Fax:
Practice Address - Street 1:61 PAQUATUCK AVE
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1205
Practice Address - Country:US
Practice Address - Phone:631-747-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician