Healthcare Provider Details

I. General information

NPI: 1952889297
Provider Name (Legal Business Name): KATHLEEN PEROUTKA MARVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13035 W BLUEMOUND RD STE 100
BROOKFIELD WI
53005-8001
US

IV. Provider business mailing address

13035 W BLUEMOUND RD STE 100
BROOKFIELD WI
53005-8001
US

V. Phone/Fax

Practice location:
  • Phone: 262-784-1121
  • Fax: 262-784-9777
Mailing address:
  • Phone: 262-784-1121
  • Fax: 262-784-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: