Provider Demographics
NPI:1861994915
Name:MORANVILLE, KATELYNN SUE
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:SUE
Last Name:MORANVILLE
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 1:5503 SILVER SAGE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-5014
Mailing Address - Country:US
Mailing Address - Phone:925-639-5569
Mailing Address - Fax:
Practice Address - Street 1:2821 CROW CANYON RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1659
Practice Address - Country:US
Practice Address - Phone:510-999-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty