Provider Demographics
NPI:1740897552
Name:COVENTRY, KATELYN LOUIS
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:LOUIS
Last Name:COVENTRY
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 1:1486 DONEGAL DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6057
Mailing Address - Country:US
Mailing Address - Phone:404-405-5113
Mailing Address - Fax:
Practice Address - Street 1:2740 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6291
Practice Address - Country:US
Practice Address - Phone:321-622-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT20135515106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician