MEDICARE: MRS. KATIE DONALDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417685967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATIE DONALDSON

Provider Business Mailing Address
First Line	:	2062 N LARK PL
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-3326
Country	:	US
Telephone Number	:	208-316-9313
Fax Number	:

Provider Business Practice Location Address
First Line	:	2062 N LARK PL
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-3326
Country	:	US
Telephone Number	:	208-316-9313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2022
Last Update Date	:	09/14/2022

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Directions to “ MRS. KATIE DONALDSON ” Practice Location

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