Provider Demographics
NPI:1972279180
Name:HAITHCOX, KATELYN PAIGE (LMBT)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:PAIGE
Last Name:HAITHCOX
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1126
Mailing Address - Country:US
Mailing Address - Phone:704-604-0903
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1126
Practice Address - Country:US
Practice Address - Phone:704-604-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14932225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist