Provider Demographics
NPI:1790526572
Name:GREEN, KATELYN SIOBHAN (MED)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:SIOBHAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:S
Other - Last Name:STOCKTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11940 W HONEYSUCKLE AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8080
Mailing Address - Country:US
Mailing Address - Phone:208-350-1761
Mailing Address - Fax:
Practice Address - Street 1:11940 W HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-8080
Practice Address - Country:US
Practice Address - Phone:208-350-1761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst