Basic Information
| Provider Information | |||||||||
| NPI: | 1255615159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUDZELKO | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | TSARYK | ||||||||
| OtherFirstName: | OLGA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 CUMMINGS CENTER | ||||||||
| Address2: | SUITE 266T | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789211190 | ||||||||
| FaxNumber: | 9789273724 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 CUMMINGS CENTER | ||||||||
| Address2: | SUITE 266T | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789211190 | ||||||||
| FaxNumber: | 9789273724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.