Basic Information
| Provider Information | |||||||||
| NPI: | 1720614340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTNER | ||||||||
| FirstName: | KATELIN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BEHAVIOR TECHNITION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5447 HAMPTON PL | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486049284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892527044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5447 HAMPTON PL | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486049284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892527044 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2020 | ||||||||
| LastUpdateDate: | 03/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | MI | Y |
ID Information
| ID | Type | State | Issuer | Description | 390816848 | 05 | MI | MEDICAID |