Provider Demographics
NPI:1679083059
Name:STEVENS, KATELYN MARIE
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 C COURT
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4577
Mailing Address - Country:US
Mailing Address - Phone:440-998-4210
Mailing Address - Fax:440-998-6489
Practice Address - Street 1:2801 C COURT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-4210
Practice Address - Fax:440-998-6489
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303737101YP2500X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0388473Medicaid