Provider Demographics
NPI:1518773035
Name:KATIES WAY DUPONT
Entity type:Organization
Organization Name:KATIES WAY DUPONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-320-6616
Mailing Address - Street 1:1175 CENTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-7733
Mailing Address - Country:US
Mailing Address - Phone:253-260-6521
Mailing Address - Fax:253-397-3443
Practice Address - Street 1:1175 CENTER DR STE 130
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-7733
Practice Address - Country:US
Practice Address - Phone:253-260-6521
Practice Address - Fax:253-397-3443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KATIES WAY TACOMA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty