Provider Demographics
NPI:1659403236
Name:PERUSEK, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PERUSEK
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 1:114 ANDERSON FERRY RD
Mailing Address - Street 2:APT 89
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-5960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5701 DELHI RD
Practice Address - Street 2:HEALTH SCIENCE DEPARTMENT
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45233-1669
Practice Address - Country:US
Practice Address - Phone:513-244-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0026082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH22OtherATHLETIC TRAINER