Provider Demographics
NPI:1093303026
Name:KAITTER, MALORY LYN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MALORY
Middle Name:LYN
Last Name:KAITTER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 OLSON MEMORIAL HWY STE 4003
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5164
Mailing Address - Country:US
Mailing Address - Phone:612-315-0019
Mailing Address - Fax:763-595-7293
Practice Address - Street 1:5101 OLSON MEMORIAL HWY STE 4003
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5164
Practice Address - Country:US
Practice Address - Phone:612-315-0019
Practice Address - Fax:763-595-7293
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN272741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty