Provider Demographics
NPI:1659179984
Name:EDWARDS, KATELYN ELIZABETH (MS)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:EDWARDS
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N CENTURY DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7726
Mailing Address - Country:US
Mailing Address - Phone:540-514-8310
Mailing Address - Fax:
Practice Address - Street 1:1306 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902
Practice Address - Country:US
Practice Address - Phone:920-409-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1350-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst