Provider Demographics
NPI:1962984971
Name:DATSKO, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:DATSKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 PEACHTREE INDUSTRIAL BLVD APT 1109
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5576
Mailing Address - Country:US
Mailing Address - Phone:586-871-7019
Mailing Address - Fax:
Practice Address - Street 1:1630 PEACHTREE INDUSTRIAL BLVD APT 1109
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-5576
Practice Address - Country:US
Practice Address - Phone:586-871-7019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2021-09-06
Deactivation Date:2018-10-06
Deactivation Code:
Reactivation Date:2019-10-14
Provider Licenses
StateLicense IDTaxonomies
MI18-64273106S00000X
GA1-21-52663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician