Provider Demographics
NPI:1770009854
Name:PODUSKA, KATHLEEN VICTORIA (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:VICTORIA
Last Name:PODUSKA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:VICTORIA
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4159 LOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-1658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5298
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-23176101YP2500X
CO0014263101YP2500X
IDLCPC-8421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional