Provider Demographics
NPI:1578868410
Name:PEROUTKA, KATHLEEN J
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:J
Last Name:PEROUTKA
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 1:1845 PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2426
Mailing Address - Country:US
Mailing Address - Phone:937-239-0170
Mailing Address - Fax:
Practice Address - Street 1:3131 S DIXIE DR
Practice Address - Street 2:SUITE 534
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-2256
Practice Address - Country:US
Practice Address - Phone:937-239-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE2063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional