Provider Demographics
NPI:1801399852
Name:ELM, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:ELM
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 1:3313 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-6326
Mailing Address - Country:US
Mailing Address - Phone:949-939-7493
Mailing Address - Fax:
Practice Address - Street 1:3313 GREENLEAF DR
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92823-6326
Practice Address - Country:US
Practice Address - Phone:949-939-7493
Practice Address - Fax:949-939-7493
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2000035600OtherBOARD OR CERTIFICATION