Provider Demographics
NPI:1629510300
Name:KOUTNIK, IRENE MARIE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MARIE
Last Name:KOUTNIK
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 1:4274 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-4758
Mailing Address - Country:US
Mailing Address - Phone:541-274-9870
Mailing Address - Fax:
Practice Address - Street 1:9123 E MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-2088
Practice Address - Country:US
Practice Address - Phone:619-504-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-15-0361-12057106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician