Provider Demographics
NPI:1407677313
Name:ETTINGER, KATELYN DENISE (LMBT)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:DENISE
Last Name:ETTINGER
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CAMELIA WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4828
Mailing Address - Country:US
Mailing Address - Phone:918-331-7096
Mailing Address - Fax:
Practice Address - Street 1:10 CAMELIA WAY
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4828
Practice Address - Country:US
Practice Address - Phone:918-331-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist