Basic Information
| Provider Information | |||||||||
| NPI: | 1023544525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROUT | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 823 | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435520823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194910420 | ||||||||
| FaxNumber: | 5676987875 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192416191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S1500251 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | S1500251 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1437626587 | 01 | OH | GROUP NPI | OTHER | 0280800 | 05 | OH | MEDICAID |