Provider Demographics
NPI:1083013593
Name:COULTER, KATIE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:COULTER
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALDEN HEIGHTS DR
Mailing Address - Street 2:APT 512
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6808
Practice Address - Country:US
Practice Address - Phone:803-434-6812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer