Provider Demographics
NPI:1508801176
Name:SALAS, KATIE D (PHD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:D
Last Name:SALAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:DESTOUET
Other - Last Name:SALAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1295
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77574-1295
Mailing Address - Country:US
Mailing Address - Phone:281-316-0709
Mailing Address - Fax:281-316-0699
Practice Address - Street 1:620 W MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3777
Practice Address - Country:US
Practice Address - Phone:281-316-0709
Practice Address - Fax:281-316-0699
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23875103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX260031510OtherRR MEDICARE
TX260031508OtherRR MEDICARE
TX098882601Medicaid
TX098882602Medicaid
TX81540POtherBCBS
TX00J25PMedicare PIN
TX81540PMedicare PIN