Provider Demographics
NPI:1356806699
Name:KOSTELANSKY, KATHERINE ELISABETH
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELISABETH
Last Name:KOSTELANSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ELISABETH
Other - Last Name:KOSTELANSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3307 HIGH VIEW CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-7210
Mailing Address - Country:US
Mailing Address - Phone:724-766-1692
Mailing Address - Fax:
Practice Address - Street 1:3307 HIGH VIEW CT
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-7210
Practice Address - Country:US
Practice Address - Phone:724-766-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency