Provider Demographics
NPI:1669015707
Name:WOLLENBURG, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WOLLENBURG
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 1:412 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-1213
Mailing Address - Country:US
Mailing Address - Phone:308-995-6585
Mailing Address - Fax:
Practice Address - Street 1:412 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-1213
Practice Address - Country:US
Practice Address - Phone:308-995-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2019009394103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool