1427421932 NPI number — KATELYN DIANE BURNS MS, LCGC

Table of content: KATELYN DIANE BURNS MS, LCGC (NPI 1427421932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427421932 NPI number — KATELYN DIANE BURNS MS, LCGC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNS
Provider First Name:
KATELYN
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LCGC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HODGE
Provider Other First Name:
KATELYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427421932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-944-3966
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2015

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: 170300000X , with the licence number:  74000100A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 74000100A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300025598 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com