Provider Demographics
NPI:1114543030
Name:SMITH, KAITLIN (BCBA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-1065
Mailing Address - Country:US
Mailing Address - Phone:910-789-1271
Mailing Address - Fax:
Practice Address - Street 1:101 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7000
Practice Address - Country:US
Practice Address - Phone:919-375-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-20-42661103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty