Provider Demographics
NPI:1972096667
Name:SOUDERS, KATIE (MA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:SOUDERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1508
Mailing Address - Country:US
Mailing Address - Phone:484-896-8238
Mailing Address - Fax:
Practice Address - Street 1:46 TRIFECTA PL STE 105
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-5652
Practice Address - Country:US
Practice Address - Phone:304-725-4536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst