Basic Information
| Provider Information | |||||||||
| NPI: | 1750572798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOSIE | ||||||||
| FirstName: | KATHRINE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2168447601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 6382 | OH | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 9262092 | 01 | OH | AETNA | OTHER | 000000225212 | 01 | OH | UNISON | OTHER | 000000538209 | 01 | OH | ANTHEM | OTHER | 421805 | 01 | OH | WELLCARE | OTHER | 2771040 | 05 | OH | MEDICAID |