Provider Demographics
NPI:1811592025
Name:HARRELSON, KATELYN JOY
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:JOY
Last Name:HARRELSON
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 1:1290 MOUNT ESTES DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3654
Mailing Address - Country:US
Mailing Address - Phone:719-217-0298
Mailing Address - Fax:
Practice Address - Street 1:11681 VOYAGER PKWY STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3864
Practice Address - Country:US
Practice Address - Phone:719-344-9342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-137601106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician