Provider Demographics
NPI:1376056150
Name:HELLDOERFER, KATELYN ROSE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:HELLDOERFER
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 1:5209 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 CROSS POINTE RD STE D
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6692
Practice Address - Country:US
Practice Address - Phone:614-407-6513
Practice Address - Fax:937-998-1118
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1800906101YM0800X
OH171M00000X
OHE.2001924101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0286682Medicaid