Provider Demographics
NPI:1235770579
Name:MOODY, KATELIN NOLAN
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:NOLAN
Last Name:MOODY
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 1:210 ASH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583-1080
Mailing Address - Country:US
Mailing Address - Phone:608-604-4040
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST # 480
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-355-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6638026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist