Healthcare Provider Details

I. General information

NPI: 1235770579
Provider Name (Legal Business Name): KATELIN NOLAN MOODY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST # 480
BARABOO WI
53913-2183
US

IV. Provider business mailing address

210 ASH ST APT 2
SAUK CITY WI
53583-1080
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4200
  • Fax:
Mailing address:
  • Phone: 608-604-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6638026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: