Healthcare Provider Details

I. General information

NPI: 1134709413
Provider Name (Legal Business Name): KATHRYN O CZERVIONKE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 COUNTY ROAD 156
TOWN CREEK AL
35672-5564
US

IV. Provider business mailing address

1064 COUNTY ROAD 156
TOWN CREEK AL
35672-5564
US

V. Phone/Fax

Practice location:
  • Phone: 256-762-4241
  • Fax:
Mailing address:
  • Phone: 256-762-4241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3702
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: