Provider Demographics
NPI:1700502705
Name:THAIN, KATELYN ANN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANN
Last Name:THAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ANN
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1322 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-4109
Mailing Address - Country:US
Mailing Address - Phone:260-515-0950
Mailing Address - Fax:
Practice Address - Street 1:5920 DECATUR RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-3640
Practice Address - Country:US
Practice Address - Phone:260-257-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33010658A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker