MEDICARE: JULIA ANNE KOLOUCH M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1790463354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA ANNE KOLOUCH M.ED.

Provider Business Mailing Address
First Line	:	200 E NAVAJO ST
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-2155
Country	:	US
Telephone Number	:	617-283-7231
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E NAVAJO ST
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-2155
Country	:	US
Telephone Number	:	617-283-7231
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	07/05/2023

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