Provider Demographics
NPI:1699575266
Name:CRAIN, KATELYN R
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:R
Last Name:CRAIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:SOWASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4547 WOODMAN RD SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9604
Mailing Address - Country:US
Mailing Address - Phone:231-313-6391
Mailing Address - Fax:
Practice Address - Street 1:4547 WOODMAN RD SW
Practice Address - Street 2:
Practice Address - City:SOUTH BOARDMAN
Practice Address - State:MI
Practice Address - Zip Code:49680-9604
Practice Address - Country:US
Practice Address - Phone:231-313-6391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant