Provider Demographics
NPI:1487264388
Name:POWELL, KATIE LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:POWELL
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 1:807 NOTRE DAME DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1785
Mailing Address - Country:US
Mailing Address - Phone:636-544-5303
Mailing Address - Fax:
Practice Address - Street 1:338 BROADWAY ST STE 301
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7331
Practice Address - Country:US
Practice Address - Phone:573-579-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020024884103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst