Provider Demographics
NPI:1356095491
Name:KELLAR, KATELYN NICOLE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:NICOLE
Last Name:KELLAR
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 1:2522 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4002
Mailing Address - Country:US
Mailing Address - Phone:318-795-3388
Mailing Address - Fax:
Practice Address - Street 1:2522 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4002
Practice Address - Country:US
Practice Address - Phone:318-795-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARBT-21-180448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty