Provider Demographics
NPI:1063698850
Name:KUCICH, LINDSEY (EDS)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:KUCICH
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32582 WILDFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2552
Mailing Address - Country:US
Mailing Address - Phone:702-234-0708
Mailing Address - Fax:
Practice Address - Street 1:32582 WILDFLOWER DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2552
Practice Address - Country:US
Practice Address - Phone:702-234-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA220040341103TS0200X
CALEP3826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool