Provider Demographics
NPI:1265036107
Name:GEDRAITIS, KATHLEEN CAIN (LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CAIN
Last Name:GEDRAITIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 NORTHLAND DR NE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7246
Mailing Address - Country:US
Mailing Address - Phone:616-884-0895
Mailing Address - Fax:
Practice Address - Street 1:65 S MAIN ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1286
Practice Address - Country:US
Practice Address - Phone:616-884-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional