Provider Demographics
NPI:1447644398
Name:CODDAIRE, KATELYN CHRISTINA (MA, LLP, LPC, CBIS)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:CHRISTINA
Last Name:CODDAIRE
Suffix:
Gender:F
Credentials:MA, LLP, LPC, CBIS
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:CHRISTINA
Other - Last Name:BEALS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LLP, LPC, CBIS
Mailing Address - Street 1:3135 PROFESSIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:734-677-4600
Mailing Address - Fax:
Practice Address - Street 1:3135 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104
Practice Address - Country:US
Practice Address - Phone:734-677-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014746101YP2500X
MI6301015429103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional