=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336650191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELYN RABAGO MS, PSYD STUDENT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2017
-----------------------------------------------------
Last Update Date | 09/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 BROADWAY STE 6
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80221-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-596-0475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 KNOBCONE DR UNIT 202
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-360-0057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------