Provider Demographics
NPI:1912362583
Name:HANEY, KATELYN (LMP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:HANEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15418 MAIN ST
Mailing Address - Street 2:106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9030
Mailing Address - Country:US
Mailing Address - Phone:425-742-6034
Mailing Address - Fax:425-742-6035
Practice Address - Street 1:15418 MAIN ST
Practice Address - Street 2:106
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9030
Practice Address - Country:US
Practice Address - Phone:425-742-6034
Practice Address - Fax:425-742-6035
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60561371225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist