Provider Demographics
NPI:1457984668
Name:BEHM, KATHERINE ELIZABETH
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:BEHM
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 1:1211 E KENNEDY BLVD UNIT 125
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3543
Mailing Address - Country:US
Mailing Address - Phone:770-238-9471
Mailing Address - Fax:
Practice Address - Street 1:1111 N PARKWAY FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-0400
Practice Address - Country:US
Practice Address - Phone:863-644-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114563400Medicaid