Healthcare Provider Details

I. General information

NPI: 1962984971
Provider Name (Legal Business Name): KATELYN DATSKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date: 10/06/2018
Reactivation Date: 10/14/2019

III. Provider practice location address

1630 PEACHTREE INDUSTRIAL BLVD APT 1109
SUWANEE GA
30024-5576
US

IV. Provider business mailing address

1630 PEACHTREE INDUSTRIAL BLVD APT 1109
SUWANEE GA
30024-5576
US

V. Phone/Fax

Practice location:
  • Phone: 586-871-7019
  • Fax:
Mailing address:
  • Phone: 586-871-7019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-52663
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-64273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: