Provider Demographics
NPI:1083497846
Name:SHOEMAKER, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SHOEMAKER
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 1:4712 WENTWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-4725
Mailing Address - Country:US
Mailing Address - Phone:317-260-1933
Mailing Address - Fax:
Practice Address - Street 1:4712 WENTWORTH BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-4725
Practice Address - Country:US
Practice Address - Phone:317-260-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009371A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical