Provider Demographics
NPI:1902453442
Name:BOETTCHER, KATELYN MARY
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARY
Last Name:BOETTCHER
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 1:3822 CAMEO PL NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-5459
Mailing Address - Country:US
Mailing Address - Phone:507-250-5538
Mailing Address - Fax:
Practice Address - Street 1:1470 INDUSTRIAL DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0700
Practice Address - Country:US
Practice Address - Phone:507-322-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician