Provider Demographics
NPI:1871335885
Name:DAVIS, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:DAVIS
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 1:2975 N RECORDS AVE APT O102
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6933
Mailing Address - Country:US
Mailing Address - Phone:907-717-8084
Mailing Address - Fax:
Practice Address - Street 1:1075 E PARK BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7722
Practice Address - Country:US
Practice Address - Phone:208-369-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician