Provider Demographics
NPI:1578161469
Name:KRIEGER, KATELYN SOUTHERN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:SOUTHERN
Last Name:KRIEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 RIVERGLEN DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2524
Mailing Address - Country:US
Mailing Address - Phone:980-428-0016
Mailing Address - Fax:
Practice Address - Street 1:10430 HARRIS OAK BLVD STE L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7513
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC16052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty