Provider Demographics
NPI:1518597285
Name:CLEGG, KATIE (RTR)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CLEGG
Suffix:
Gender:F
Credentials:RTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2803
Mailing Address - Country:US
Mailing Address - Phone:541-690-4925
Mailing Address - Fax:
Practice Address - Street 1:593 W 24TH ST
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2803
Practice Address - Country:US
Practice Address - Phone:541-690-4925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OR9105692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician