MEDICARE: KATHRYN PEROVICH

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	225X00000X	Occupational Therapist	105493	MN

General Provider Information

NPI Number	:	1871012815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN PEROVICH

Provider Business Mailing Address
First Line	:	2555 COUNTY ROAD E E STE 102
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4906
Country	:	US
Telephone Number	:	651-683-2953
Fax Number	:	651-705-0051

Provider Business Practice Location Address
First Line	:	2555 COUNTY ROAD E E STE 102
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4906
Country	:	US
Telephone Number	:	651-683-2953
Fax Number	:	651-705-0051

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

Provider Enumeration Date	:	09/11/2017
Last Update Date	:	07/21/2022

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