Provider Demographics
NPI:1700492139
Name:SPAIN, KATELYN M
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:M
Last Name:SPAIN
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 1:687 KNOX ST N APT 98
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1118
Mailing Address - Country:US
Mailing Address - Phone:971-207-9517
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE STE 340
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7903
Practice Address - Country:US
Practice Address - Phone:503-655-8045
Practice Address - Fax:503-655-6806
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health