Provider Demographics
NPI:1104484542
Name:MOLDENHAUER, KATIE (BCBA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MOLDENHAUER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15756 STEVENSON PL
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1037
Mailing Address - Country:US
Mailing Address - Phone:219-741-1851
Mailing Address - Fax:219-464-4318
Practice Address - Street 1:2101 COMEFORD RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8385
Practice Address - Country:US
Practice Address - Phone:219-462-6705
Practice Address - Fax:219-464-4318
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-32946103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst