Healthcare Provider Details

I. General information

NPI: 1790026417
Provider Name (Legal Business Name): KATIE LAUREN KILLEBREW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2762 WAVERLEY DR
TROPHY CLUB TX
76262-3424
US

IV. Provider business mailing address

3805 MOORCROFT RD
FRISCO TX
75036-8226
US

V. Phone/Fax

Practice location:
  • Phone: 469-768-0308
  • Fax:
Mailing address:
  • Phone: 361-648-1295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number36387
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: