Provider Demographics
NPI:1811611718
Name:DETHLEFS, KATELYN MARIE
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:DETHLEFS
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 1:13808 W MAPLE RD STE 124
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3791
Practice Address - Country:US
Practice Address - Phone:402-804-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician