Healthcare Provider Details

I. General information

NPI: 1790463354
Provider Name (Legal Business Name): JULIA ANNE KOLOUCH M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E NAVAJO ST
WEST LAFAYETTE IN
47906-2155
US

IV. Provider business mailing address

200 E NAVAJO ST
WEST LAFAYETTE IN
47906-2155
US

V. Phone/Fax

Practice location:
  • Phone: 617-283-7231
  • Fax:
Mailing address:
  • Phone: 617-283-7231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: