Provider Demographics
NPI:1750945168
Name:BATES, KATHERINE MERIDETH
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MERIDETH
Last Name:BATES
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 1:202 HUNTERS GLEN LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9560
Mailing Address - Country:US
Mailing Address - Phone:515-360-8704
Mailing Address - Fax:
Practice Address - Street 1:3510 PARMENTER ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-1522
Practice Address - Country:US
Practice Address - Phone:920-650-4879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI552-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist