Provider Demographics
NPI:1043975147
Name:KING, KATELAN MEREDITH (PTA, CBIS)
Entity type:Individual
Prefix:MS
First Name:KATELAN
Middle Name:MEREDITH
Last Name:KING
Suffix:
Gender:F
Credentials:PTA, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12825 PRAIRIE MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-8510
Mailing Address - Country:US
Mailing Address - Phone:515-991-4900
Mailing Address - Fax:
Practice Address - Street 1:950 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4274
Practice Address - Country:US
Practice Address - Phone:815-381-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008275225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant