Provider Demographics
NPI:1083208219
Name:QUEEN, KATLIN
Entity Type:Individual
Prefix:
First Name:KATLIN
Middle Name:
Last Name:QUEEN
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 1:150 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4198
Mailing Address - Country:US
Mailing Address - Phone:216-202-0785
Mailing Address - Fax:
Practice Address - Street 1:150 HOLLY LN
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4198
Practice Address - Country:US
Practice Address - Phone:216-202-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid