Provider Demographics
NPI:1891091799
Name:DJUKIC, KATHLEEN J (LSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:DJUKIC
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 S MARGINAL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-1072
Mailing Address - Country:US
Mailing Address - Phone:216-221-7588
Mailing Address - Fax:
Practice Address - Street 1:5500 S MARGINAL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1072
Practice Address - Country:US
Practice Address - Phone:216-221-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00253371041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid