Provider Demographics
NPI:1912417445
Name:DOUD, KATRINA MAE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:MAE
Last Name:DOUD
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 W CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9307
Mailing Address - Country:US
Mailing Address - Phone:989-941-1656
Mailing Address - Fax:
Practice Address - Street 1:1234 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1818
Practice Address - Country:US
Practice Address - Phone:989-245-3681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty