Provider Demographics
NPI:1699357749
Name:BLUE, KATELYN ANNA
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANNA
Last Name:BLUE
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 1:1018 N BRAGG BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-3316
Mailing Address - Country:US
Mailing Address - Phone:910-295-2609
Mailing Address - Fax:
Practice Address - Street 1:1018 N BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3316
Practice Address - Country:US
Practice Address - Phone:910-295-2609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician