Provider Demographics
NPI:1124427406
Name:KASULKE, STEPHANIE MARY
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARY
Last Name:KASULKE
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 1:36 FIRETOWN RD
Mailing Address - Street 2:GOVERNOR'S HOUSE NURSING HOME
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1965
Mailing Address - Country:US
Mailing Address - Phone:860-658-1018
Mailing Address - Fax:
Practice Address - Street 1:36 FIRETOWN RD
Practice Address - Street 2:GOVERNOR'S HOUSE NURSING HOME
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1965
Practice Address - Country:US
Practice Address - Phone:860-658-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018673-1225X00000X
CT004413225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist