Provider Demographics
NPI:1356831127
Name:CLEVENGER, KATELYN MARIE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:CLEVENGER
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 1:6847 JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-1447
Mailing Address - Country:US
Mailing Address - Phone:937-371-2105
Mailing Address - Fax:
Practice Address - Street 1:2430 VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2555
Practice Address - Country:US
Practice Address - Phone:937-878-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician