Provider Demographics
NPI:1528857984
Name:THIBODEAUX, KATELYNN STARR
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:STARR
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATELYNN
Other - Middle Name:STARR
Other - Last Name:CLOTFELTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4402 LAWRENCEVILLE RD STE 225
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6780
Mailing Address - Country:US
Mailing Address - Phone:678-225-8858
Mailing Address - Fax:470-945-3225
Practice Address - Street 1:4402 LAWRENCEVILLE RD STE 225
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6780
Practice Address - Country:US
Practice Address - Phone:678-225-8858
Practice Address - Fax:470-945-3225
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS001152237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist