Provider Demographics
NPI:1083206874
Name:RICKETTS, KATELYN (MS, CCC-SLP, IBCLC)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:MS, CCC-SLP, IBCLC
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:KLUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2001 N LOY LAKE RD STE J
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 N LOY LAKE RD STE J
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2837
Practice Address - Country:US
Practice Address - Phone:903-487-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-301926174N00000X
TX114013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty