Provider Demographics
NPI:1063011153
Name:MEDINA, KATELYN BROOKE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:BROOKE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:BROOKE
Other - Last Name:LOCKLEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8879
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28814-8879
Mailing Address - Country:US
Mailing Address - Phone:866-700-1606
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK RD STE 218B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0157511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical