Provider Demographics
NPI:1679944763
Name:MARTIN, KATELYN ELIZABETH (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3173B CANARY CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-4508
Mailing Address - Country:US
Mailing Address - Phone:228-731-9598
Mailing Address - Fax:
Practice Address - Street 1:4061 SUZANNE DR
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540
Practice Address - Country:US
Practice Address - Phone:228-396-4434
Practice Address - Fax:228-396-4438
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS180058103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst