Provider Demographics
NPI:1083196620
Name:BAWCOM, KATELYN MOLLY (STUDENT INTERN)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MOLLY
Last Name:BAWCOM
Suffix:
Gender:F
Credentials:STUDENT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 KOSTER ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-0106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 KOSTER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0106
Practice Address - Country:US
Practice Address - Phone:707-269-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool