Provider Demographics
NPI:1053073569
Name:DEITZ, CAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:DEITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 JACKSON PKWY
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-6920
Mailing Address - Country:US
Mailing Address - Phone:518-669-6148
Mailing Address - Fax:
Practice Address - Street 1:2507 JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-6920
Practice Address - Country:US
Practice Address - Phone:518-669-6148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA898101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health