Provider Demographics
NPI:1790026417
Name:KILLEBREW, KATIE LAUREN
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LAUREN
Last Name:KILLEBREW
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 1:3805 MOORCROFT RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-8226
Mailing Address - Country:US
Mailing Address - Phone:361-648-1295
Mailing Address - Fax:
Practice Address - Street 1:2762 WAVERLEY DR
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-3424
Practice Address - Country:US
Practice Address - Phone:469-768-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363872355S0801X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX149984001Medicaid
TX207164901Medicaid