Provider Demographics
NPI:1093999757
Name:KATHMAN, KEVIN JOSEPH (ORT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:KATHMAN
Suffix:
Gender:M
Credentials:ORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5515
Mailing Address - Country:US
Mailing Address - Phone:812-333-5915
Mailing Address - Fax:812-333-5919
Practice Address - Street 1:583 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5515
Practice Address - Country:US
Practice Address - Phone:812-333-5915
Practice Address - Fax:812-333-5919
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002806A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200199360Medicaid
IN199290HMedicare PIN