Provider Demographics
NPI:1518625979
Name:WALKER, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:WALKER
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 1:3110A BENT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1921
Mailing Address - Country:US
Mailing Address - Phone:865-604-3630
Mailing Address - Fax:
Practice Address - Street 1:5285 HIGHWAY N STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-7733
Practice Address - Country:US
Practice Address - Phone:314-529-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020043216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020043216OtherSTATE