MEDICARE: MS. KATHLEEN MARY DURLAK L.P.C.C.

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	101YM0800X	Mental Health Counselor	E 880	OH

General Provider Information

NPI Number	:	1245210426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN MARY DURLAK L.P.C.C.

Provider Business Mailing Address
First Line	:	2600 FAR HILLS AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-1687
Country	:	US
Telephone Number	:	937-133-5343
Fax Number	:	937-233-5543

Provider Business Practice Location Address
First Line	:	2600 FAR HILLS AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-1687
Country	:	US
Telephone Number	:	937-133-5343
Fax Number	:	937-233-5543

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

Provider Enumeration Date	:	01/22/2006
Last Update Date	:	07/08/2007

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