Provider Demographics
NPI:1528405024
Name:POLLOM, KATIE ELIZABETH (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:POLLOM
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ELIZABETH
Other - Last Name:WATIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:9929 E. 126TH STREET
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038
Mailing Address - Country:US
Mailing Address - Phone:317-319-6617
Mailing Address - Fax:
Practice Address - Street 1:9929 E 126TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-9404
Practice Address - Country:US
Practice Address - Phone:317-319-6617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-12-10310103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst