Basic Information
| Provider Information | |||||||||
| NPI: | 1891091799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DJUKIC | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 S MARGINAL RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441031072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162217588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5500 S MARGINAL RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441031072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162217588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S.0025337 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0268768 | 05 | OH | MEDICAID |