Provider Demographics
NPI:1083315881
Name:CARPENTER, KAITLIN (SSP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 PATHWAYS XING
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5885
Mailing Address - Country:US
Mailing Address - Phone:618-355-4433
Mailing Address - Fax:
Practice Address - Street 1:2411 PATHWAYS XING
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5885
Practice Address - Country:US
Practice Address - Phone:618-355-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1267804103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool