1467752030 NPI number — MS. KATHRYN ELIZABETH KILCULLEN LCDC

Table of content: MS. KATHRYN ELIZABETH KILCULLEN LCDC (NPI 1467752030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467752030 NPI number — MS. KATHRYN ELIZABETH KILCULLEN LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILCULLEN
Provider First Name:
KATHRYN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCDC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILCULLEN
Provider Other First Name:
KATIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCDC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467752030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15400 KNOLL TRAIL DR
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75248-3467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-738-2747
Provider Business Mailing Address Fax Number:
972-392-9041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15400 KNOLL TRAIL DR
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75248-3467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-738-2747
Provider Business Practice Location Address Fax Number:
972-392-9041
Provider Enumeration Date:
10/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCDC 5614 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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