Healthcare Provider Details

I. General information

NPI: 1619514270
Provider Name (Legal Business Name): KATELYN MARIE HERATY LGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 EASTON AVE
NEW BRUNSWICK NJ
08901-1766
US

IV. Provider business mailing address

254 EASTON AVE
NEW BRUNSWICK NJ
08901-1766
US

V. Phone/Fax

Practice location:
  • Phone: 732-745-6659
  • Fax: 732-249-2687
Mailing address:
  • Phone: 732-745-6659
  • Fax: 732-249-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number246000256
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number25MJ00045700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: