Provider Demographics
NPI:1366097735
Name:JANUSZ, KATHLEEN CLARE (OTR, MED)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:CLARE
Last Name:JANUSZ
Suffix:
Gender:F
Credentials:OTR, MED
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:CLARE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 E STATE HIGHWAY 114
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5236
Mailing Address - Country:US
Mailing Address - Phone:682-305-0657
Mailing Address - Fax:
Practice Address - Street 1:700 E STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5236
Practice Address - Country:US
Practice Address - Phone:682-305-0657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120147225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist