Provider Demographics
NPI:1548759269
Name:KOUTASSEVITCH, KATRIN LYNN
Entity Type:Individual
Prefix:
First Name:KATRIN
Middle Name:LYNN
Last Name:KOUTASSEVITCH
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 1:690 E GREEN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2197
Mailing Address - Country:US
Mailing Address - Phone:626-765-1519
Mailing Address - Fax:626-765-1519
Practice Address - Street 1:690 E GREEN ST STE 204
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2197
Practice Address - Country:US
Practice Address - Phone:626-795-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical