Provider Demographics
NPI:1023841681
Name:SUDHALTER, KATIE (LPC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:SUDHALTER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E HOLLY ST APT 106
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7884
Mailing Address - Country:US
Mailing Address - Phone:303-704-1901
Mailing Address - Fax:
Practice Address - Street 1:10448 W GARVERDALE CT STE 606
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5474
Practice Address - Country:US
Practice Address - Phone:303-704-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
IDCOUI-10543101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health