Provider Demographics
NPI:1932957875
Name:WAREHAM, KATELIN MW
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:MW
Last Name:WAREHAM
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 1:149 S 200 W
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6058
Mailing Address - Country:US
Mailing Address - Phone:208-313-9080
Mailing Address - Fax:
Practice Address - Street 1:130 SOUTH LINCOLN
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-313-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program