Provider Demographics
NPI:1407560105
Name:PROVO, KATEY
Entity Type:Individual
Prefix:
First Name:KATEY
Middle Name:
Last Name:PROVO
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 1:1385 E FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5237
Mailing Address - Country:US
Mailing Address - Phone:831-917-3293
Mailing Address - Fax:
Practice Address - Street 1:875 RAYS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WHISPERING PINES
Practice Address - State:NC
Practice Address - Zip Code:28327-5910
Practice Address - Country:US
Practice Address - Phone:888-392-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician