Provider Demographics
NPI:1558806117
Name:PALMER, KATIE (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 S SHADYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7053
Mailing Address - Country:US
Mailing Address - Phone:206-240-1288
Mailing Address - Fax:
Practice Address - Street 1:2939 S SHADYWOOD WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716
Practice Address - Country:US
Practice Address - Phone:206-240-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT146.0119641103K00000X
WABA60934056103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst