Provider Demographics
NPI:1033409677
Name:KAITLYN LAURIE, S.C
Entity Type:Organization
Organization Name:KAITLYN LAURIE, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAITLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURIE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:605-235-3546
Mailing Address - Street 1:6320 MONONA DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3952
Mailing Address - Country:US
Mailing Address - Phone:608-235-3546
Mailing Address - Fax:
Practice Address - Street 1:6320 MONONA DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3952
Practice Address - Country:US
Practice Address - Phone:608-235-3546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-17
Last Update Date:2011-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1915125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42221000Medicaid