Provider Demographics
NPI:1114508033
Name:KILLEEN, KATHERINE ANN
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:KILLEEN
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 1:3211 MORGANFORD RD APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1831
Mailing Address - Country:US
Mailing Address - Phone:314-489-5530
Mailing Address - Fax:
Practice Address - Street 1:1804 LAFAYETTE AVE FL 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2508
Practice Address - Country:US
Practice Address - Phone:314-296-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health